COVID-19 Daily Staff and Visitor Screening Form
As per Toronto Public Health and Ministry of Education regulations, staff at UMC High School must complete this form every workday BEFORE arriving to school in order to gain entry into the school building.  

Visitors must submit this form upon arrival or complete a paper-based copy at the front entrance in order to enter the building.

This form is used to record information related to the health, safety and well-being of staff to enhance safety at UMC High School. Information will only be shared with Toronto Public Health if/when requested. Questions about this collection can be directed to the Manager, Toronto Public Health at 416-338-7600.
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Date: *
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Staff Name: *
Department: *
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Q1: In the last [5, 10] days have you experienced any of these symptoms? *
•If you are fully vaccinated AND/OR 11 years old or younger, use 5 days •If you are 12 years old or older and not fully vaccinated OR if you are immunocompromised, use 10 days. Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea) and should seek assessment from their health care provider if needed. Household members of individuals with any of the below symptoms should stay home at the same time as the person who is sick, regardless of vaccination status. If you are symptomatic and tested negative for COVID-19 on a single PCR test or rapid molecular test, or two rapid antigen tests (RATs) taken 24-48 hours apart, you do not have a fever, and symptoms have been improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea), you may answer “no” to all symptoms. Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
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Q2: In the last [5, 10] days have you experienced any of these symptoms? *
•If you are fully vaccinated AND/OR 11 years old or younger, use 5 days. •If you are 12 years old or older and not fully vaccinated OR if you are immunocompromised, use 10 days. You may select “No” to all symptoms if you tested negative for COVID-19 on a PCR test, a rapid molecular test, or two rapid antigen tests taken 24 to 48 hours apart AND you do not have a fever and your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea).Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
Required
Q3: In the last [5, 10] days have you tested positive for COVID-19? *
This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test or home-based self-testing kit. •If you are fully vaccinated AND/OR 11 years old or younger, use 5 days. •If you are 12 years old or older and not fully vaccinated OR if you are immunocompromised, use 10 days. Select “No” if you have already completed your isolation period of [5, 10] days because your symptoms started before your positive test result AND:•your symptoms have been improving for 24 hours (48 for nausea, vomiting, and/or diarrhea) AND •you do not have a fever
Q4: Do any of the following apply? *
•You live with someone who is currently isolating because of a positiveCOVID-19 test. •You live with someone who is currently isolating because of COVID-19symptoms (any one or more symptoms from question 1 above or any two or more symptoms from question 2 above)•You live with someone who is waiting for COVID-19 test results. Select “No” if you completed your isolation after testing positive in the last90 days (using a rapid antigen, rapid molecular, or PCR test).
Q5. In the last [5, 10] days, have you been identified as a “close contact” of someone who currently has COVID-19 or has symptoms of COVID-19 (any one or more symptoms from question 1 above or any two or more symptoms from question 2 above)? *
•If you are fully vaccinated AND/OR 11 years old or younger, use 5 days •If you are 12 years old or older and not fully vaccinated OR if you are immunocompromised, use 10 days. Select “No” if any of the following apply:•You are fully vaccinated, not immunocompromised, and you do not live with the person who has COVID-19•You completed your isolation after testing positive in the last 90 days(using a rapid antigen, rapid molecular, or PCR test)•Contact with the person who has COVID-19 or symptoms of COVID-19only occurred within a school or child care setting. Note: Given the multiple protective strategies in place, contacts who are only exposed at school or child care are not generally considered close contacts requiring isolation
Q6: Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *
This can be because of an outbreak or contact tracing.
Q7: Do any of the following apply? *
•In the last 14 days, you travelled outside of Canada and were told to quarantine. •In the last 14 days, you travelled outside of Canada and were told to not attend school/child care. •In the last 14 days, someone you live with returned from travelling outside of Canada and is isolating while awaiting results of a COVID-19 test.
I understand that if I have answered YES to any of the above questions or have any current symptoms, I should NOT come to school and will contact the school to notify about the absence and reason. You can call 416-438-0707 or message your Student Marketer. *
Do Not Come To School if you have answered YES to ONE OR MORE of the above symptoms, you MUST stay home to isolate immediately, and not leave except to get tested for COVID-19, to be assessed by a health care provider or for a medical emergency. Please contact the school at 416-438-0707 or message your Student Marketer.
COVID-19 Screening - Notice with Respect to the Collection, Use and Disclosure of Personal Health Information
The information pertaining to your COVID-19 Screening is being collected, used and disclosed under the authority of the Health Protection and Promotion Act R.S.O 1990 c.H.7 and will be retained, used, disclosed and disposed of in accordance with all applicable municipal, federal and provincial laws and regulations governing the collection, use, disclosure and disposal of information including the Municipal Freedom of Information and Protection of Privacy Act R.S.O. 1990 c.M.5 and the Personal Health Information Protection Act 2004 S.O. 2004 c.3.
This information will be used by Toronto Public Health to investigate the occurrence of COVID-19 in the city of Toronto, and provide case management, follow-up with close contacts to assess the risk to others, program planning and evaluation to reduce the risk of spread of COVID-19. Any questions, regarding this collection, use or disclosure may be directed to the Medical Officer of Health, Toronto Public Health, 416-338-7600.
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