COVID-19 Screening Form

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COVID-19 Screening Form - Pod 1

Answer the following questions before going to school today.

Name: (one per student/participant) *

Are you:

- living in a highest risk congregate care setting (for example, a hospital school, an Education and Community Partnership Program) and/or

- immunocompromised (for this question, factors such as old age, diabetes and end-stage renal disease are generally not considered immunocompromised)

Examples of being immunocompromised include those:

- undergoing cancer chemotherapy

- with untreated HIV infection with CD4 T lymphocyte count less than 200

- with combined primary immunodeficiency disorder

- on prednisone medication

- more than 20 mg per day (or equivalent) for more than 14 days

- on other immune suppressive medications

1 point

Yes

Do you have any of these symptoms?

Choose any or all that are new, worsening and not related to other known causes or conditions.

Select "None of the above" if both of these apply:

- you do not have a fever and

- your symptoms have been improving for at least 24 hours (48 hours if you had nausea, vomiting and/or diarrhea)

1 point

Fever and/or chills

Cough (Not related to other known causes or conditions (for example, chronic obstructive pulmonary disease))

Shortness of breath (Not related to other known causes or conditions (for example, asthma, chronic obstructive pulmonary disease, chronic heart failure))

Decrease or loss of taste or smell Not related to other known causes or conditions (for example, nasal polyps, allergies, neurological disorders))

Muscle ache or joint pain Not related to other known causes or conditions (for example, getting a COVID-19 vaccine and/or flu shot in the last 48 hours, osteoarthritis, fibromyalgia))

Extreme tiredness General feeling of being unwell, lack of energy and not related to other known causes or conditions (for example, getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, anemia, malignancy)

Sore throat (Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have))

Runny or stuffy/congested nose Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather, chronic sinusitis)

Headache Not related to other known causes or conditions (for example, getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines))

Nausea, vomiting, and/or diarrhea Not related to other known causes or conditions (for example, transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effects of medication))

Abdominal pain (Not related to other known causes or conditions (for example, transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effects of medication))

Pink eye (Not related to other known causes or conditions (for example, blepharitis, recurrent styes)

Decreased or no appetite (young children only) (Not related to other known causes or conditions (for example, anxiety, constipation))

None of the above

Required

Have you been told that you should currently be quarantining, isolating, staying at home, or not attending school or child care?

Could include being told by a doctor, health care provider, public health unit, federal border agent, or other government authority.

Please note there are federal requirements for individuals who travelled outside of Canada, even if exempt from quarantine.

1 point

Yes

In the last 10 days, have you tested positive for COVID‐19?

This includes a positive COVID‐19 test result on a laboratory-based PCR test, rapid molecular test, rapid antigen test, or other home-based self-testing kit.

1 point

Yes

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This form was created inside of Wheatley School.