Klub Care Elboya Daily Health Check
Thank you for helping keep everyone safe. The Alberta government is requiring this form be filled out every morning before your child can attend Klub.

You will receive a copy of your responses in your email. That email is confirmation that the form was filled out. If you do not receive a copy of the form, please try again, or have one of the staff at the program fill it out for you.
Email address *
Which Family is this for? *
1. Has your child: *
Yes
No
Traveled outside Canada in the last 14 days? When entering or returning to Alberta from outside Canada, individuals are legally required to quarantine for 14 days unless enrolled in the Alberta COVID-19 International Border Pilot Project
Had close contact with a case of COVID-19 in the last 14 days? Face-to-face contact within 2 metres for 15 minutes or longer, or direct physical contact such as hugging
If the child answered “YES” to any of the above: The child is required to quarantine for 14 days from the last day of exposure. If the child is participating in the Alberta COVID-19 International Border Pilot Project, they must comply with the program restrictions at all times. If the child develops any symptoms, use the AHS Online Assessment Tool or call Health Link811 to determine if testing is recommended.
If the child answered “NO” to both of the above: Proceed to question 2.
2. Does the child have any new onset (or worsening) of the following core symptoms: *
Yes
No
Fever - Temperature of 38 degrees Celsius or higher
Cough - Continuous, more than usual, not related to other known causes or conditions such as asthma
Shortness of breath - Continuous, out of breath, unable to breathe deeply, not related to other known causes or conditions such as asthma
Loss of sense of smell or taste - Not related to other known causes or conditions like allergies or neurological disorders
If the child answered “YES” to any symptom in question 2, the child is to isolate for 10 days from onset of symptoms. Use the AHS Online Assessment Tool or call Health Link 811 to arrange for testing and to receive additional information on isolation.
If the child answered “NO” to all of the symptoms in question 2: Proceed to question 3.
3. Does the child have any new onset (or worsening) of the following other symptoms: *
Yes
No
Chills - Without fever, not related to being outside in cold weather
Sore throat/painful swallowing - Not related to other known causes/conditions, such as seasonal allergies or reflux
Runny nose/congestion - Not related to other known causes/conditions, such as seasonal allergies or being outside in cold weather
Feeling unwell/fatigued - Lack of energy, poor feeding in infants, not related to other known causes or conditions, such as depression, insomnia, thyroid dysfunction or sudden injury
Nausea, vomiting and/or diarrhea - Not related to other known causes or conditions, such as anxiety, medication or irritable bowel syndrome
Unexplained loss of appetite - Not related to other known causes or conditions, such as anxiety or medication
Muscle/joint aches - Not related to other known causes or conditions, such as arthritis or injury
Headache - Not related to other known causes or conditions, such as tension-type headaches or chronic migraines
Conjunctivitis (commonly known as pink eye)
If the child answered “YES” to ONE symptom in question 3, keep your child home and monitor for 24 hours. If their symptom is improving after 24 hours, they can return to school and activities when they feel well enough to go. Testing is not necessary.
If the symptom does not improve or worsens after 24 hours (or if additional symptoms emerge), use the AHS Online Assessment Tool or call Health Link 811 to check if testing
is recommended.
If the child answered “YES” to TWO OR MORE symptoms in question 3, keep your child home. Use the AHS Online Assessment Tool or call Health Link 811 to determine if testing is recommended. Your child can return to school and activities once their symptoms go away as long as it has been at least 24 hours since their symptoms started.
If the child answered “NO” to all questions, your child may attend school, child care and/or other activities.
A copy of your responses will be emailed to the address you provided.
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