Archbishop Carney Covid-19 Health & Screening Form
Instructions: All employees, students and visitors must complete this form once per month before being admitted to Archbishop Carney Regional Secondary School facilities. Archbishop Carney Regional Secondary School reserves the right to refuse admittance to any person on the basis of their responses to the questions posed and information obtained by this form.
Last Name: *
By placing your name on this form you are certifying that the information on this form is TRUE and COMPLETE.
First Name: *
By placing your name on this form you are certifying that the information on this form is TRUE and COMPLETE.
Select from the following: *
Phone Number: *
For the purpose of public health and safety we are requiring a means of contacting you to meet contact tracing guidelines set by the BC Ministry of Health.
Do you have any of the following new key symptoms? *
Yes
No
Fever
Chills
Cough or worsening of chronic cough
Shortness of breath
Loss of sense of smell or taste
Diarrhea
Nausea and vomiting
If you answered "YES" to one of the questions included under 'Key Symptoms of Illness' (excluding fever), you should stay home for 24 hours from when the symptom started. If the symptom improves, you may return to school when you feel well enough. If the symptom persists or worsens, seek a health assessment.
If you answered "YES" to two or more of the questions included under 'Key Symptoms of Illness', or you have a fever, seek a health assessment. A health assessment includes calling 8-1-1, or a primary care provider like a physician for nurse practitioner. If a health assessment is required, you should not return to school until COVID-19 has been excluded and your symptoms have improved.
Please answer the following two questions: *
Yes
No
Have you returned from travel outside Canada in the last 14 days?
Are you a confirmed contact of a person confirmed to have COVID-19?
If you answered YES to either of the questions in the question directly above, use the COVID-19 Self-Assessment Tool to determine if you should seek testing for COVID-19. The link for the Self-Assessment Tool is: https://bc.thrive.health/covid19/en
Submit
Never submit passwords through Google Forms.
This form was created inside of Archbishop Carney Regional Secondary School. Report Abuse