Wellness Survey Week Ten
This survey is to assist in determining the health and well-being of our class participants. Our goal is to minimize the risk of infection to our staff and children, thank you for your understanding and cooperation. If you have answered YES to any of the below questions, please DO NOT attend class today. If you have answered NO to all of the below questions, remember to sign in and out and practice hand hygiene (wash hands for 20 seconds, and/or use hand sanitizer) before and after you visit.
Do you, or your child attending the program, have any of the following below symptoms? *
Yes
No
Fever
Cough
Shortness of Breath / Difficulty Breathing
Chills
Painful swallowing
Runny Nose / Nasal Congestion
Feeling unwell / Fatigued
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Loss of sense of taste or smell
Muscle / Joint Aches
Headache
Congunctivitis (Pink eye)
Has your child travelled outside of Canada in the last 14 days or has someone in the household travelled outside of Canada in the last 14 days and is ill? *
Have you or your children attending the program had close unprotected contact (face-to-face within 2 meters) in the last 14 days with someone who is ill with cough and/or fever? *
Have you or anyone in your household been in close unprotected contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?
Clear selection
Parent and/or Guardian Consent *
Required
Child(ren) Name(s) *
Parent Name *
Date *
MM
/
DD
/
YYYY
Submit
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