Active Screening Questionnaire for Manor Park Community Council staff.
Active Screening is a review of your health. Completing Active Screening DAILY is a mandate of the Ministry of Health, Ministry of Education, and Ottawa Public Health for all staff working in child care or recreation. Submitting this Questionnaire to the Manor Park Community Council (MPCC) makes it easy for you to comply.
It helps everyone remain safe and healthy!
Information collected will only be used by the MPCC for the administration and management of its child care and recreation programs. Information will only be shared as legally required.
Do you have one or more of the following symptoms? Check all that apply. If you have one or more symptom, please stay home from work and notify your supervisor immediately.
Fever (37.8 degrees C or higher)
Cough that's new or worsening (continuous, more than usual)
Barking cough, making a whistling noise when breathing (croup)
Shortness of breath (unable to breathe deeply or feeling unable to catch one's breath)
Sore throat (not related to seasonal allergies or other known conditions)
Runny, stuffy, or congested nose (not associated with allergies or other known condition)
Lost sense of taste or smell
Pink eye (conjunctivitis)
Headache that's unusual or long-lasting
Diarrhea or stomach pain
Nausea or vomiting
Extreme tiredness that is unusual (fatigue, lack of energy)
Falling down often
Sluggishness or lack of appetite
None of the above
Have any of your household contacts (family, roommates) or other contacts outside of the MPCC presented with Covid-19 symptoms in the last 14 days?
I attest that: I have NOT travelled outside of Canada (including the United States) in the last 14 days; I have NOT had close contact with a confirmed or probable Covid-19 case, and I have NOT had close contact with a person with acute respiratory illness who has been outside of Canada (including the United States) in the last 14 days.
Yes, I attest.
No, I do not attest.
Notice of Risk from Ottawa Public Health:
When children from multiple families attend a child care or recreational program, there is an increased risk of the Covid-19 virus coming into the program. Children who are infected with the Covid-19 virus are more likely than adults to have very mild infections or to have no symptoms at all, but these children can still transmit the infection to other children and to adults. This means that children can bring home an infection acquired in a child care or recreational program and put other persons at risk. Even if a program has a screening process to help detect infections when there are symptoms, this screening process will not detect infected children or adults who do not have symptoms at the time of screening.
The risk of serious Covid-19 infection increases with age, which older staff should consider in terms of risk to themselves, particularly if working in programs with children from multiple families. This caution also applies to those persons of any age who have chronic medical conditions that may put them at increased risk for serious illness with Covid-19 infection.
I am familiar with the Covid-19 Prevention Policies of the Manor Park Community Council -- found on
-- including 'Workplace Safety Plan' and 'Response Plan'.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service