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COVID SCREEN
Please complete the following screening for each member of your family that is attending Fresh Start programming:
First Name
Last Name
How to contact me:
Choose an option
Email
Phone Number
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Enter Phone Number
Enter Email Address
What program are you participating in?
Choose an option
Circle of Security
Volunteering
Drop In Programming
Staff Screening
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1. Do you hve any of the following symptoms?
No.
Fever about 37.8C
Chills
Cough or barking cough (croup)
Shortness of breath
Sore throat
Difficulty swallowing
Decrease or loss of tasts or smell
Pink eye
Runny or stuffy/congested nose
Headache
Digestive issues like nausea/vomiting, diarrhea, stomach pain
Muscle aches
Extreme tiredness
Falling down often
2. Have you traveled internationally within the last 14 days (outside Canada)?
Yes
No
3. Have you had close contact (within 6 feet for more than 15 minutes) with anyone that has tested positive for COVID-19 ?
Yes
No
4. Have you had close contact (within 6 feet for more than 15 minutes) with someone that has COVID-19 like symptoms in the last 14 days?
Yes
No
5. Have you had contact with anyone in self-isolation or awaiting the results of a COVID-19 test in the past 14 days?
Yes
No
Is there any other information that you would like to disclose at this time?
Your Signature (To be signed by the legal guardian if screen was completed by someone less than 16 years of age)
Clear
Continue
COVID SCREEN
Please complete the following screening for each member of your family that is attending Fresh Start programming:
First Name
Last Name
How to contact me:
Choose an option
Email
Phone Number
arrow&v
Enter Phone Number
Enter Email Address
What program are you participating in?
Choose an option
Circle of Security
Volunteering
Drop In Programming
Staff Screening
arrow&v
1. Do you hve any of the following symptoms? Please check all that apply.
Fever about 37.8C
Chills
Cough or barking cough (croup)
Shortness of breath
Sore throat
Difficulty swallowing
Decrease or loss of tasts or smell
Pink eye (only applies to those over 18)
Runny or stuffy/congested nose
Headache
Nausea/vomiting, diarrhea or stomach pain
Muscle aches
Extreme tiredness
Falling down often (only applies to those over 18)
No, I do not have any of the above symptoms
2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
Yes
No
3. In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?
Yes
No
4. In thte last 14 days, have you received a COVID alert exposure notification on your cell phone?
Yes
No
5. In the last 14 days, have you or anyone you live with travelled outside of Canada?
Yes
No
6. Is anyone you live with currently experiencing any new COVID-19 Symptoms and/or waiting for test results after experiencing symptoms?
Yes
No
Is there any other information that you would like to disclose at this time?
Your Signature (To be signed by the legal guardian if screen was completed by someone less than 16 years of age)
Clear
Continue