Harmony Child Screening Form
Harmony Childcare Centre will be conducting screening prior to allowing children to enter the day care. Please complete this form on behalf of your child prior to arriving at the centre. Upon arriving at Harmony's screening area, this form will be reviewed and your child's temperature will be taken and recorded. A wellness check will be conducted at the screening area as well.

If you have multiple children attending the centre, you will be required to complete an online screening form for each child. This needs to be completed for ALL children attending a program here - PreS, JK, SK and SA.

Daily submissions CANNOT BE SUBITTED PRIOR TO 6:00 a.m. on the day your child is expected in care or the submission will be considered invalid and you'll have to complete it again or fill out a paper copy once you get to the day care.

ALL OF THE QUESTIONS ARE FOR "NEW OR WORSENING" SYMPTOMS. ALL SYMPTOMS LISTED BELOW SHOULD NOT BE CHRONIC OR RELATED TO OTHER KNOW CAUSES OR CONDITIONS.

Full Name of Parent/Guardian Completing Form *
Emergency Phone Number *
Child's First Name *
Child's Last Name *
Classroom child is attending: *
Required
# 1 A. FEVER *
A FEVER and/or CHILLS of 37.8 C / 100 F or greater.
A FEVER and/or CHILLS of 37.8 C / 100 F or greater.
# 1 B. COUGH. More than the usual if chronic cough...including croup (barking cough, making a whistling noise when breathing). Not related to other known causes or conditions (e.g. asthma, reactive airway) *
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# 1 C. SHORTESS OF BREATH (dyspnea, out of breath, unable to breathe deeply, wheeze...that is worse than usual if chronically short of breath) Not related to other known causes or conditions (e.g. asthma) *
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#1 D. DECREASE OR LOSS OF SMELL OR TASTE (new olfactory or taste disorder) Not related to other known causes or conditions (e.g. nasal polyps, allergies, neurological disorders) *
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#2 A. SORE THROAT (painful swallowing or difficulty swallowing) *
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# 2 B. STUFFY NOSE and/or RUNNY NOSE (nasal congestion and/or rhonorrhea) *
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# 2 C. HEADACHE that is new and persistant, unusual, unexplained or long-lasting. *
# 2 D. NAUSEA, VOMITING and/or DIARRHEA *
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# 2 E. FATIGUE, LETHARGY, MUSCLE ACHES OR MALAISE (general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained. *
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# 3. Has your child travelled outside of Canada in the past 14 days? *
# 4. Has your child been identified as a close contact of someone who is confirmed as having COVID-19 by your local public health unit (or from the COVID Alert app if they have their own phone)? *
# 5. Has your child been directed by a health care provider including public health official to isolate? *
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