Jackman Community Daycare Screening Form
The most important thing families can do to help slow the spread of COVID-19, is to screen their children daily for any COVID-19 symptoms and keep them home from daycare if they are sick or have had close contact with anyone diagnosed with COVID-19.

Review this COVID-19 checklist daily with your child(ren) and household members to confirm that they do not have any symptoms or have had other exposure to COVID-19. We all have a role in keeping our daycare safe and healthy.  

Multiple children can be listed on one form, however parents must ask each child these questions individually.

Information is based on TPH COVID-19 screening for child care settings dated April 28, 2022

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𝐂𝐡𝐢𝐥𝐝(𝐫𝐞𝐧) 𝐍𝐚𝐦𝐞(𝐬) 𝐟𝐢𝐫𝐬𝐭 𝐚𝐧𝐝 𝐥𝐚𝐬𝐭: *
𝐍𝐚𝐦𝐞 𝐨𝐟 𝐏𝐞𝐫𝐬𝐨𝐧 𝐂𝐨𝐦𝐩𝐥𝐞𝐭𝐢𝐧𝐠 𝐭𝐡𝐞 𝐟𝐨𝐫𝐦: *
𝐈𝐟 𝐭𝐡𝐞 𝐚𝐧𝐬𝐰𝐞𝐫 𝐢𝐬 "𝐘𝐄𝐒" 𝐭𝐨 𝐪𝐮𝐞𝐬𝐭𝐢𝐨𝐧𝐬 𝐥𝐢𝐬𝐭𝐞𝐝 𝐢𝐧 #𝟏𝐀 𝐨𝐫 #𝟏𝐁:  𝐒𝐭𝐚𝐲 𝐡𝐨𝐦𝐞 𝐚𝐧𝐝 𝐬𝐞𝐥𝐟 𝐢𝐬𝐨𝐥𝐚𝐭𝐞 + 𝐘𝐨𝐮𝐫 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝 𝐦𝐮𝐬𝐭 𝐬𝐞𝐥𝐟-𝐢𝐬𝐨𝐥𝐚𝐭𝐞 * (exceptions for household member isolation provided under additional information)  
𝟏. 𝐀) 𝐃𝐨 𝐲𝐨𝐮 𝐨𝐫 𝐚𝐧𝐲𝐨𝐧𝐞 𝐢𝐧 𝐭𝐡𝐞 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝 𝐡𝐚𝐯𝐞 𝟏 𝐨𝐫 𝐦𝐨𝐫𝐞 𝐨𝐟 𝐭𝐡𝐞𝐬𝐞 𝐧𝐞𝐰 𝐨𝐫 𝐰𝐨𝐫𝐬𝐞𝐧𝐢𝐧𝐠 𝐬𝐲𝐦𝐩𝐭𝐨𝐦𝐬, 𝐭𝐨𝐝𝐚𝐲, 𝐨𝐫 𝐢𝐧 𝐭𝐡𝐞 𝐥𝐚𝐬𝐭 𝟓 𝐨𝐫 𝟏𝟎 𝐝𝐚𝐲𝐬*?   *
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𝟏. 𝐁) 𝐃𝐨 𝐲𝐨𝐮 𝐨𝐫 𝐚𝐧𝐲𝐨𝐧𝐞 𝐢𝐧 𝐭𝐡𝐞 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝 𝐡𝐚𝐯𝐞 𝟐 𝐨𝐫 𝐦𝐨𝐫𝐞 𝐨𝐟 𝐭𝐡𝐞𝐬𝐞 𝐧𝐞𝐰 𝐨𝐫 𝐰𝐨𝐫𝐬𝐞𝐧𝐢𝐧𝐠 𝐬𝐲𝐦𝐩𝐭𝐨𝐦𝐬 𝐭𝐨𝐚𝐝𝐲, 𝐨𝐫 𝐢𝐧 𝐭𝐡𝐞 𝐥𝐚𝐬𝐭 𝟓 𝐨𝐫 𝟏𝟎 𝐝𝐚𝐲𝐬 *?   𝑰𝒇 𝒚𝒐𝒖 𝒉𝒂𝒗𝒆 𝒐𝒏𝒆 𝒔𝒚𝒎𝒑𝒕𝒐𝒎 𝒇𝒓𝒐𝒎 𝒑𝒂𝒓𝒕 𝑩, 𝒔𝒕𝒂𝒚 𝒉𝒐𝒎𝒆 𝒖𝒏𝒕𝒊𝒍 𝒔𝒚𝒎𝒑𝒕𝒐𝒎𝒔 𝒊𝒎𝒑𝒓𝒐𝒗𝒆 𝒇𝒐𝒓 𝒂𝒕 𝒍𝒆𝒂𝒔𝒕 24 𝒉𝒐𝒖𝒓𝒔 𝒐𝒓 48 𝒉𝒐𝒖𝒓𝒔 𝒊𝒇 𝒏𝒂𝒖𝒔𝒆𝒂/𝒗𝒐𝒎𝒊𝒕𝒊𝒏𝒈/𝒅𝒊𝒂𝒓𝒓𝒉𝒆𝒂. *
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𝟐. 𝐇𝐚𝐯𝐞 𝐲𝐨𝐮 𝐨𝐫 𝐚𝐧𝐲𝐨𝐧𝐞 𝐢𝐧 𝐭𝐡𝐞 𝐡𝐨𝐮𝐬𝐞𝐡𝐨𝐥𝐝 𝐡𝐚𝐝 𝐚 𝐩𝐨𝐬𝐢𝐭𝐢𝐯𝐞 𝐂𝐎𝐕𝐈𝐃-𝟏𝟗 𝐭𝐞𝐬𝐭 𝐢𝐧 𝐭𝐡𝐞 𝐥𝐚𝐬𝐭 𝟓 𝐨𝐫 𝟏𝟎 𝐝𝐚𝐲𝐬*, 𝐨𝐫 𝐛𝐞𝐞𝐧 𝐭𝐨𝐥𝐝 𝐭𝐨 𝐬𝐭𝐚𝐲 𝐡𝐨𝐦𝐞 𝐚𝐧𝐝 𝐬𝐞𝐥𝐟-𝐢𝐬𝐨𝐥𝐚𝐭𝐞?  (If you had a positive test or live with someone who is isolating or awaiting test results select "Yes".)   *
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*   You or household members do not need to self-isolate if no symptoms and not had a positive test and either: had a confirmed COVID-19 infection within 90 days***; OR are 18 + and boosted****; OR are 17 years or younger and fully vaccinated**.
𝟑. 𝐈𝐧 𝐭𝐡𝐞 𝐥𝐚𝐬𝐭 𝟏𝟒 𝐝𝐚𝐲𝐬, 𝐡𝐚𝐯𝐞 𝐲𝐨𝐮 𝐭𝐫𝐚𝐯𝐞𝐥𝐥𝐞𝐝 𝐨𝐮𝐭𝐬𝐢𝐝𝐞 𝐨𝐟 𝐂𝐚𝐧𝐚𝐝𝐚? *
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𝐈 𝐜𝐨𝐧𝐟𝐢𝐫𝐦 𝐭𝐡𝐚𝐭 𝐦𝐲 𝐚𝐧𝐬𝐰𝐞𝐫𝐬 𝐭𝐨 𝐭𝐡𝐞 𝐚𝐛𝐨𝐯𝐞 𝐪𝐮𝐞𝐬𝐭𝐢𝐨𝐧𝐬 𝐚𝐫𝐞 𝐚𝐜𝐜𝐮𝐫𝐚𝐭𝐞. *
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