Child Online Screening Form

Child Screening

Child Information

Screening Questions - Section 1

1. Does your child have any of the following new or worsening symptoms?
Symptoms should not be chronic or related to other known causes or conditions.

Screening Questions - Section 2

2. Does your child have any of the following new or worsening symptoms?
Symptoms should not be chronic or related to other known causes or conditions.

Additional Screening Questions

These Instructions show if you answered “YES” to any of the symptoms included under question 1:

• Contact the school/child care to let them know about this result.
• They should isolate (stay home) and not leave except to get tested or for a medical emergency.
• Talk with a doctor/health care provider to get advice or an assessment, including if they need a COVID-19 test.
• Household members without symptoms may go to school/child care/work. Check your local public health unit’s website or call to see if they have different rules based on local risk.

These Instructions show if you answered “YES” to only one of the symptoms included under question 2:

• Contact the school/child care to let them know about this result.
• They should isolate (stay home) for 24 hours and not leave except for a medical emergency.
• After 24 hours if their symptom is improving, they can return to school/child care when they feel well enough to go. They do not need to get tested.
• Household members without symptoms may go to school/child care/work. Check your local public health unit’s website or call to see if they have different rules based on local risk.

These Instructions show if you answered “YES” to two or more of the symptoms included under question 2:

• Contact the school/child care to let them know about this result.
• They should isolate (stay home) for 24 hours and not leave except for a medical emergency.
• After 24 hours if their symptom is improving, they can return to school/child care when they feel well enough to go. They do not need to get tested.
• Household members without symptoms may go to school/child care/work. Check your local public health unit’s website or call to see if they have different rules based on local risk.

These Instructions show if you answered “YES” to question 3, 4 or 5:

• Contact the school/child care to let them know about this result.
• They should isolate (stay home) for 24 hours and not leave except for a medical emergency.
• After 24 hours if their symptom is improving, they can return to school/child care when they feel well enough to go. They do not need to get tested.
• Household members without symptoms may go to school/child care/work. Check your local public health unit’s website or call to see if they have different rules based on local risk.

Parent/Guardian Contact Information

By checking the box below, I hereby declare that:
The information provided is to the best of my knowledge accurate, truthful
& correct in all respects, and I have not omitted to disclose any information. *