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

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