Nursery School Pre-Screening Form - Rural Family Connections

Name*

First Last

Date*

Phone*

Program Site*

Children*

Has your child traveled outside of Canada in the last 14 days and was told to quarantine (as per the federal quarantine requirements)?*

Yes
No

Has a doctor, health care provider, or public health unit told you and/or your child(ren) that they should currently be isolating or staying at home?*

This can be because of an outbreak, contact tracing, or after testing positive on a rapid antigen test.

Yes
No

Does your child have any of the following 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 37.8°C/100.0°F or higher)
Cough or barking cough (croup) (continuous, more than usual, making a whistling noise when breathing, not related to asthma, post-infectious reactive airways)
Shortness of breath (out of breath, unable to breathe deeply, not related to asthma)
Decrease or loss of smell or taste (not related to seasonal allergies, neurological disorders)
Nausea, vomiting and/or diarrhea (not related to irritable bowel syndrome, anxiety, menstrual cramps)
No symptoms

Does your child have any of the following symptoms?

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

Sore throat (painful swallowing, not related to seasonal allergies, acid reflux, post nasal drip)
Runny or stuffy-congested nose (not related to seasonal allergies, being outside in cold weather, chronic sinusitis unchanged from baseline)
Conjunctivitis (Pink Eye) (not related to blepharitis, recurrent styes)
Decreased or lack of appetite (not related to anxiety, constipation)
Headache (new and persistent, unusual, unexplained, or long-lasting (not related to tension-type headaches, chronic migraines, or receiving a COVID-19 vaccine in the last 48 hours)
Extreme tiredness, lack of energy or feeling unwell (that is unusual or unexpected, not related to other known causes or conditions or receiving a COVID-19 vaccine in the last 48 hours)
Muscle aches and pains (that are unexplained or unusual, not related to other known causes or conditions or receiving a COVID-19 vaccine in the last 48 hours)
No symptoms

In the last 10 days, has your child tested positive on a rapid antigen test or a home-based self-testing kit?*

If your child has since tested negative on a lab-based PCR test, answer 'no.'

Yes
No

You can go to work/school today. Please submit your form, and we'll see you soon.

For the continued health and safety of our staff and students, we ask that you please remain at home today. Thank you.

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Metcalfe Nursery School Covid-19 Pre-screening

COVID-19 Procedures

Pre-Screening Form

You can go to work/school today. Please submit your form, and we'll see you soon.

For the continued health and safety of our staff and students, we ask that you please remain at home today. Thank you.