COVID Screening Questionnaire

We are currently taking measures to limit the risk of infection and to ensure the safety of you and your family, and the safety of our staff. To help us prevent the spread of COVID-19, we ask you to read the questionnaire carefully and fill in the form below.

Your Name *

Your Email *

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

Location *

-- Your location --Queensborough

Room *

Tiny Squirts - Infant (age 1 - 2)Tiny Tots - Toddler (age 2 - 3)Tiny Tykes - Junior Kindergarten (age 3 - 5)

Has the child experienced any of the following in the last 24 hours? *
Fever • Cough • Shortness of Breath/Difficulty Breathing • Sore throat • Chills • Painful Swallowing • Runny Nose • Nasal Congestion • Feeling Unwell/Fatigued • Nausea/Vomiting/ Diarrhea • Unexplained loss of appetite • Loss of sense of taste or smell • Muscle/Joint aches • Headache • Conjunctivitis
YesNo

Has the child received any type of fever reducer in the last 24 hours? *

YesNo

Has the child or any family member living in the same household been recently diagnosed with COVID-19? *
YesNo

Has the child or any family member living in the same household had signs or symptoms of COVID-19 and has been tested for COVID-19 but is awaiting results of that test? *
YesNo

Has the child or any family member living in the same household had reasonable grounds to believe they have symptoms of COVID-19? *
YesNo

Has the child or any family member living in the same household been in contact with anyone who has tested positive or is self isolating? *
YesNo

Travel Outside of Canada in past 14 days? *

YesNo