Screening Questionnaire

Your Name (required)

Your Email (required)

Child's Name (LAST NAME, first name) (required)

Location (required)
Your location*Global HQ (Ottawa Lisgar)BarrhavenFindlay CreekKanata BridlewoodKanata NorthOrleansOrleans AvalonRiverside SouthRocklandBarrie - Big Bay PointBurlington SouthKingston WestKingston EastKitchener SportsworldKitchener Chicopee HillsLondon SummersideMilton Sherwood ParkNewmarket SouthNorth York Wilson HeightsStoney Creek ParamountStoney Creek RymalPark LawnEdmonton SummersideEdmonton River ValleySt. Albert SouthEdmonton GatewayLangley WilloughbyLangley City CentreQueensboroughRichmond AlderbridgeSouth SurreySaudi Arabia

Room (required)
InfantToddlerPreschoolSchool age careStaff

Does the attendee have any new onset (or worsening) of any of the following symptoms:

Fever:
YesNo

Cough:
YesNo

Shortness of Breath/Difficulty Breathing:
YesNo

Sore throat:
YesNo

Chills:
YesNo

Painful Swallowing:
YesNo

Runny Nose/Nasal Congestion:
YesNo

Feeling Unwell/Fatigued:
YesNo

Nausea/Vomiting/ Diarrhea:
YesNo

Unexplained loss of appetite:
YesNo

Loss of sense of taste or smell:
YesNo

Muscle/Joint aches:
YesNo

Headache:
YesNo

Conjunctivitis:
YesNo

Has the attendee received any type of fever reducer in the last 24 hours?
YesNo

Has the attendee travelled outside of Canada in the last 14 days?
YesNo

Has the attendee had close contact with a confirmed case of COVID-19 in the last 14 days?
YesNo

Has the attendee had close contact with a symptomatic close contact of a confirmed case of COVID-19 in the last 14 days?
YesNo

*Face-to-face contact within 2 meters. A health care worker in an occupational setting wearing the recommended personal protective equipment is not considered to be a close contact.

**'Ill/symptomatic' means someone with COVID-19 symptoms on the list above

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