Active Screening Questionnaire for children in recreation programs.
Active Screening is a health review of your child. Completing Active Screening daily BEFORE participation in a recreational program is a mandate of the Ministry of Health and Ottawa Public Health. 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 Manor Park Community Council for the administration and management of 'Afternoons in the Park', as well as arts and sports programming. Information will only be shared as legally required.
Does your child have one or more of the following symptoms? Check all that apply. Those who have one or more symptom will not be able to attend the program or enter the facility.
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 your child's household contacts (family, roommates) or other contacts outside of school or child care presented with Covid-19 symptoms in the last 14 days?
As parent / guardian of this child, I attest that: my child has NOT travelled outside of Canada (including the United States) in the last 14 days; my child has NOT had close contact with a confirmed or probable Covid-19 case, and my child has 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 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 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.
I have knowledge of this child's health and attest that the information provided is true.
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