Kindergarten & Grade School Household Screening Agreement
To be completed each Sunday.

It is a requirement that you complete a self-assessment of any member(s) of your household who will be on campus at London Waldorf School prior to arriving at school each day.

Please read and sign this form weekly to confirm that you will complete daily screening for your child(ren) and to ensure you are aware of the questions required in the daily self-assessment. Additional guidance can be found through the use of the Ontario School Screening Tool available at covid-19.ontario.ca/school-screening/

Upon arrival at the screening station at the beginning of the week, we will verify that we have a record of this attestation. If one has not been completed, a paper copy will be available to be completed at that time.

***Note: one form can be completed for all household members
Child(ren)'s Last Name(s) *
Child(ren)'s First Name(s) *
At which screening station will your children be entering the school? *
QUESTION 1: In the last 14 days, has the student/child travelled outside of Canada? (If exempt from federal quarantine requirements, select "No") *
QUESTION 2: Has a doctor, health care provider, or public health unit told you that the student/child should currently be isolating(staying at home)? This can be because of an outbreak or contact tracing. *
QUESTION 3: In the last 14 days, has the student/child been identified as a "close contact" of someone who currently has COVID-19? *
QUESTION 4: In the last 14 days has the student/child received a COVID Alert exposure notification on their cell phone? If they have already went for a test and got a negative result, select "No". *
QUESTION 5: Is the student/child currently experiencing any of these symptoms? Choose any/all that are new, worsening and not related to other known causes or conditions they already have. *
Required
QUESTION 6: Is the student/child currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions they already have. *NOTE: If the student/child received a COVID-19 vaccination in the last 48 hours and are experiencing a mild symptoms from this list that only began after vaccination, do not check the symptom box. *
Required
QUESTION 7: Is someone that the student/child lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select "No." *
If you answered "YES" to questions 1 or 3 do not go to school or child care.
The student/child must isolate (stay home) for 14 days and not leave except to get tested or for a medical emergency.

If you answered “YES” to question 1, follow the advice of public health. The student/child can return to school/child care after they are cleared by your local public health unit.

If you answered “YES” to question 3, talk with a doctor/health care provider to get advice or an assessment, including if they need a COVID-19 test. The student/child can return to school/child care only after 14 days, even if they get a negative test result.

If they develop symptoms, or test positive, contact your local public health unit or doctor/health care provider for more advice.
If you answered "YES" to question 2 do not go to school or child care.
The student/child must self-isolate (stay home) and not leave except for a medical emergency.

Follow the advice of public health. The student/child can return to school/child care after they are cleared by your local public health unit.

If they develop symptoms, contact your local public health unit or doctor/health care provider for more advice.
If you answered "YES" to question 4 do not go to school or child care.
The student/child must self-isolate (stay home) and not leave except for a medical emergency.

Visit an assessment centre to get them a COVID-19 test.

If they test negative (they do not have the virus), they can return to school/child care.

If they test positive (they have the virus), they can return only after they are cleared by your local public health unit.

If you develop symptoms, contact your local public health unit or doctor/health care provider for more advice.

Siblings or other people in your household can go to school, child care or work, but must not leave the home for other, non-essential reasons until the individual who got the COVID Alert tests negative or is cleared by your local public health unit.
If you answered "YES" to any of the symptoms included under questions 5 or 6, or "YES" to question 7 do not go to school or child care.
If the student/child has received a COVID-19 vaccination in the last 48 hours and has mild headache, fatigue, muscle aches and/or joint pain that only began after immunization, and no other symptoms, they are to wear a surgical/procedure mask for their entire time at school/child care. Their mask may only be removed to consume food or drink and they must remain at least two meters away from others when their mask has been removed. If the symptoms worsen, continue past 48 hours, or if they develop other symptoms, they should be picked up from school/childcare immediately, self-isolate and seek COVID-19 testing.
By completing this form and typing my name below, I hereby agree to complete a daily household assessment prior to arriving at school in accordance with the questions laid out in this form and any current guidelines of the Middlesex London Health Unit. *
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