COVID-19 Screening Assessment (NUF House North Inc.)
*NOTE* When signing this form, you are asserting that the information is true and that you have personal knowledge of the facts contained in the form. By signing, you are also stating that you are competent to and that you are of sound mind and you are over the age of 18.

Please also note that parents are responsible for taking their Childs temperature at home. Temperature will also be taken prior to entering the daycare.
Child's Full Name *
Program Room *
Parent's Name *
Childs Temperature this morning *
1. If your child has any ONE of the following symptoms listed below, DO NOT GO TO SCHOOL OR CHILD-CARE. Stay at home and book an appointment to get a Covid-19 test OR isolate for 10 days after symptoms first started AND all household members should isolate for 14 days from their last exposure to the symptomatic contact. *
Required
2. If your child has any ONE of the following symptoms listed below, DO NOT GO TO SCHOOL OR CHILD-CARE. Stay at home for at least 48 hours (with no worsening symptoms) or get a covid-19 test if symptoms persist or worsen after 24 hours. *
Required
3. In the last 14 days, has your child travelled outside of Canada? *
4. Has a doctor, health care provider, or public health unit told you that your child should currently be isolating (staying at home)? *
5. In the last 14 days, has your child been identified as a "close contact" of someone who currently has Covid-19? *
6. In the last 14 days, have you or your child received a COVID Alert exposure notification on their mobile/cell phone? *
7. Is someone that your child lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
Thank you for completing the assessment form!
Please visit york.ca/COVID19 and york.ca/SafeAtSchool for information on ways to protect yourself, your family and your school community. Stay Safe and Take Care!
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