Covid-19 Screening Assessment - Nuf House Academy
*NOTE* When signing this form, you are asserting that the information is true and that you have personal knowledge of the facts contained in the form. By signing, you are also stating that you are competent to and that you are of sound mind and you are over the age of 18.

Please also note that parents are responsible for taking their Childs temperature at home. Temperature will also be taken prior to entering the daycare.
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Child's Last and First Name *
Parent's Name *
Todays Date
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Program Room *
Childs temperature this morning *
1. In the last [5,10] days has the student/child experienced any of the following symptoms? (If yes, do not attend school or child care.) *If the student/child is fully vaccinated OR 11 years old or younger, isolate for 5 days. *If the student/child is 12 years of age or older and not fully vaccinated OR if they are immune compromised, isolate for 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 and should seek assessment form 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. *
2. In the last [5,10] days has the student/child experienced any of the following symptoms? (If yes, do not go to school or child care) *If the student/child is fully vaccinated OR 11 years old or younger, isolate for 5 days *If the student/child is 12 years of age or older OR is not fully vaccinated OR if they are immune compromised, isolated for 10 days. *
3. In the last [5,10] days has the student/child tested positive for COVID-19? (This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test or home-based self-testing kit.) *
4. Does the student/child live with someone who is currently isolating because of COVID-19 test? Does the student/child live with someone who is currently isolating because of COVID-19 symptoms? Does the student/child live with someone who is currently isolating while waiting for COVID-19 test results? *
5. Has your child been identified as a "close contact" of someone who currently has COIVD-19 or has symptoms of COIVD-19 (any one or more symptoms from question s1 above or any two or more symptoms from questions 2)? *
6. Has a doctor, health care provider, or public health unit told you that the student/child should currently be isolation (staying at home)? *
7. In the last 14 days, has the student/child travelled outside of Canada and was told to quarantine? In the last 14 days, has the student/child travelled outside of Canada and was told not to attend school/child care? In the last 14 days, someone the student/child lives with has returned from travelling outside of Canada and is isolating while awaiting results of a COVID-19 test? *
Thank you for completing the assessment form!
Please visit york.ca/COVID19 and yok.ca/SafeAtSchool for information on ways to protect yourself, your family and your school community. Stay Safe and Take Care!
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