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For Families/Children: COVID-19 Self-Assessment Form
All children in a Big Brothers Big Sisters 1:1 match are required to complete this form prior to an in-person match meeting
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Today's Date *
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Your Child's First & Last Name *
Their Big Brother/Sister's First & Last Name *
Your Caseworker's First Name: *
Are you or your child currently experiencing any of the following symptoms that may be associated with COVID-19: fever, shortness of breath, cough that's new/worsening, sore throat, unusual fatigue, runny nose/stuffy nose or nasal congestion, nausea, vomiting, diarrhea, abdominal pain or not feeling well? *
In the last 14 days, have you or your child been identified as a "close contact" of someone who currently has COVID-19?
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Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
In the last 14 days, have you or your child travelled outside of Canada? If they are exempt from federal quarantine requirements (for example, you are fully vaccinated and have met the specific conditions), select “No.” *
Has a doctor, health care provider, or public health unit told you that you or your child should currently be isolating (staying at home)? *
Considering your answers above, and the health and safety of both you, your child, and their Big Brother/Sister, are you comfortable with them meeting for an in-person visit? *
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