COVID-19 Screening Form For Households - To be completed daily for each family

School Name: Khalsa Montessori School
School Address: 5 Cherrycrest Drive, Brampton, ON & 11499 The Gore Rd, Brampton, ON

This daily screening is required as per Daily Active Screening for Covid-19 Policy. This form must be filled for each family daily - siblings need submit only one form. Select multiple classes if siblings go to separate classes. Temperature must be recorded for each child entering the centre. If, for either child entering the centre, you answer YES to any of these questions, record the name of the child below the check box. Close contact is being coughed or sneezed on or being within 2 meters of an individual with COVID-19 symptoms for 15 minutes.

Parent/Guardian’s Name (First, Last)
Child 1:
Name (First, Last):
Class
Child 2:
Name (First, Last):
Class
Child 3:
Name (First, Last):
Class
1: In the last [5, 10] days has the student/child experienced any of these symptoms?
  • If the student/child is fully vaccinated OR 11 years old or younger, use 5 days
  • If the student/child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days

Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below,should stay home until their symptoms are improving for 24 hours and should seek assessment from their health care provider if needed. Household members of individuals with any of the below symptoms should stay home at the same time as the person who is sick, regardless of vaccination status.

If the student/child is symptomatic and has tested negative for COVID-19 on a single PCR test or two rapid antigen tests (RAT) taken 24 hours apart, and symptoms have been improving for 24 hours, you may answer “no” to all symptoms.

Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

Fever and/or chills

Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills


Cough or barking cough (croup)

Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causesor conditions they already have)


Shortness of breath

Out of breath, unable to breathe deeply(not related to asthma or other known causes or conditions they already have)

Decrease or loss of smell or taste

Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have


2: In the last [5, 10] days has the student/child experienced any of these symptoms?

  • If the student/child is fully vaccinated OR 11 years old or younger, use 5 days
  • If the student/child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days

Choose any/all that are new, worsening, and not related to other known causes or conditions they already have

Sore throat or difficulty swallowing

Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)

Runny or stuffy/congested nose

Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Headache

Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

If the student/child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing a mild headache that only began after vaccination, select “No.”

Extreme tiredness

Unusual, fatigue, lack of energy, poor feeding in infants (not related to depression,insomnia, thyroid disfunction, sudden injury, or other known causes or conditions they already have)

If the student/child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing mild fatigue and/or mild muscle aches/joint pain that only began after vaccination, select “No.”

Muscle aches or joint pain

If the student/child received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing mild fatigue and/or mild muscle aches/joint pain that only began after vaccination, select “No.

Nausea, vomiting and/or diarrhea

Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have

3.In the last [5, 10] days has the student/child tested positive for COVID-19?

This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test or home-based self-testing kit.

  • If the student/child is fully vaccinated OR 11 years old or younger, use 5 days
  • If the student/child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, use 10 days.
4. Do any of the following apply?
  • The student/child lives with someone who is currently isolating because of a positive COVID-19 test
  • The student/child lives with someone who is currently isolating because of COVID-19 symptoms
  • The student/child lives with someone who is currently isolating while waiting for COVID-19 test results

If the individual isolating has not tested positive for COVID-19 and only has one of these symptoms: sore throat or difficulty swallowing, runny or stuffy/congested nose, headache, extreme tiredness, muscle aches or joint pain, nausea, vomiting and/or diarrhea, select “No.

5. Has the student/child been identified as a “close contact” of someone who currently has COVID-19 and been advised to self-isolate?

If public health guidance provided to you has advised you that you do not need to self-isolate, select “No.”

6. Do any of the following apply?
  • In the last 14 days, the student/child travelled outside of Canada and was told to quarantine
  • In the last 14 days, the student/child travelled outside of Canada and was told to not attend school/child care
  • In the last 14 days, someone the student/child lives with has returned from travelling outside of Canada and is isolating while awaiting results of a COVID-19 test.

Please note that if the child/student is not fully vaccinated but is exempt from federal quarantine because they travelled with a vaccinated companion, they must not attend school or child care for 14 days. Select “yes” if this applies to the student/child.

7. Has a doctor, health care provider, or public health unit told you that the student/child should currently be isolating (staying at home)?

This can be because of an outbreak or contact tracing.