Nursery School Pre-Screening Form - Rural Family Connections

Name*

First Last

Date*

Phone*

Program Site*

Children*

Temperature of child(ren)*

Has your child(ren) traveled outside of Canada in the last 14 days?*

Yes
No

Has your child(ren) been in close contact with someone who has tested positive for COVID-19 in the past 14 days?*

This includes:
• living in the same house while that person was not self-isolating and infectious
• Being less than 2 metres away in the same room or area from another person or unprotected contact for more than 15 minutes

Yes
No

In the last 14 days, has your child(ren) been in close contact with someone who returned from outside of Canada?*

Yes
No

Has your child(ren)’s household contacts (family members and/or roommates) or other contacts outside of school/child care presented with any new COVID-19 symptoms?*

Ex: Cough, fever, difficulty breathing, runny nose.

Yes
No

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

This can be because of an outbreak or contact tracing.

Yes
No

Does your child(ren) have any of the following symptoms?*

Choose any/all that are new, worsening, and NOT related to other known causes or conditions.

Please visit Ottawa Public Health Reports, Research and Statistics for more information.

Rural Family Connections Covid-19 Guidelines*

I have read the COVID-19 Guidelines for Rural Family Connections.

Notice of Risk*

When children from multiple families attend a program from RFC, there is increased risk of the Covid-19 virus coming into the centres. Children who are infected with the covid-19 virus are more likely than adults to have very mild infections or to have no symptoms at all, but these children can still transmit the infection to other children and to adults in the centres. This means that children can bring home an infection acquired in the RFC programs and put others at risk. Rural Family Connections has a screening process to help detect infections when there are symptoms; however, this screening process will not detect infected children or adults who do not have symptoms at the time of screening.
The risk of serious Covid-19 infection increases with age, which older family members should consider in terms of risk to themselves personally, particularly if attending the settings with children from multiple families.

I have read and understand the notice of risk (above).

Signature

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Metcalfe Nursery School Covid-19 Pre-screening

COVID-19 Procedures

Pre-Screening Form