Faculty & Visitor Screening Agreement

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It is a requirement that you complete a self-assessment prior to arriving at school each day.

Please read and sign this form to confirm that you will complete daily screening using the criteria listed below. Additional guidance can be found through the use of the Ontario School Screening Tool available at covid-19.ontario.ca/school-screening/

Last Name(s) *

First Name(s) *

QUESTION 1: Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *

-Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

-Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions)

-Shortness of breath - Out of breath, unable to breath deeply (not related to asthma or other known causes or conditions)

-Decrease or loss of taste or smell - Not related to seasonal allergies, neurological disorders, or other known causes or conditions

-Tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No."

-Muscle aches - Unexplained, unusual, or long-lasting (not related to sudden injury, fibromyalgia, or other known causes or conditions) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”

None of the above

Required

If you answered “YES” to any of the symptoms included under question 1, do not go to school or child care.

• You must isolate (stay home) and should not leave except to get tested or for a medical
emergency.
• Talk with a doctor/health care provider to get advice or an assessment, including if you need
a COVID-19 test.
ϕ Other people in your household must stay at home until you test negative, or are cleared by
your public health unit, or are diagnosed with another illness. Household members who are
fully immunized or previously positive for COVID-19 in the last 90 days and have since been
cleared are not required to stay home.
• Contact your school/child care provider to let them know about this result.

QUESTION 2: Did you receive your final (or second in a two-dose series) COVID-19 vaccination dose more than 14 days ago, or have you tested positive for COVID-19 in the last 90 days and have since been cleared? If YES, skip questions 3, 4, 5. *

YES

QUESTION 3: Is anyone you live 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.” *

YES

If you answered “YES” to question 3, do not go to school or child care.

• You must isolate (stay home) and should not leave except to get tested or for a medical
emergency.
• You can return to school or child care after the individual with symptoms tests negative and is
cleared by your local public health unit, or is diagnosed with another illness.
• Contact your school/child care provider to let them know about this result.

QUESTION 4: In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate, select “No." *

YES

If you answered “YES” to question 4, do not go to school or child care.

• You must isolate (stay home) for 10 days and not leave except to get tested or for a medical
emergency.
• Talk with a doctor/health care provider to get advice or an assessment, including if you need a
COVID-19 test. You can only return to school/child care after 10 days, even if you get a negative
test result, as long as you do not develop any symptoms.
ϕ Other people in your household can go to school, child care or work, but must not leave
the home for other non-essential reasons. Household members who are fully immunized or
previously positive for COVID-19 in the last 90 days and have since been cleared are
not required to stay home.
• If you develop symptoms or test positive, contact your local public health unit or doctor/health
care provider for more advice.
• Contact your school/child care provider to let them know about this result.

QUESTION 5: In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select “No." *

YES

If you answered “YES” to question 5, do not go to school or child care.

You must isolate (stay home) and should not leave except to get tested or for a medical
emergency.
• Visit an assessment centre to get a COVID-19 test.
ϕ If you test negative (you do not have the virus), you can return to school/child care. ϕ If you test positive (you have the virus), you need to continue isolating and can return only
after you 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.
ϕ 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. Household members who are
fully immunized or previously positive for COVID-19 in the last 90 days and have since been
cleared are not required to stay home.
• Contact your school/child care provider to let them know about this result.

QUESTION 6: In the last 14 days, have you travelled outside of Canada and been advised to quarantine as per the federal quarantine requirements? *

YES

If you answered “YES” to question 6, do not go to school or child care

• You must isolate (stay home) for 14 days and not leave except to get tested or for a medical
emergency.
• Follow the advice of public health. You can return to school/child care after you have completed
your federal quarantine requirement.
• If you develop symptoms and/or test positive, contact your local public health unit or doctor/
health care provider for more advice.
• Contact your school/child care provider to let them know about this result.

QUESTION 7: Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing. *

YES

If you answered “YES” to question 7, do not go to school or child care.

• You must isolate (stay home) and should not leave except to get tested or for a medical
emergency.
• Follow the advice of public health. You can return to school/child care after you 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.
ϕ Other people in your household must stay at home until you test negative, or are cleared by
your public health unit. Household members who are fully immunized or previously positive
for COVID-19 in the last 90 days and have since been cleared are not required to stay home.
• Contact your school/child care provider to let them know about this result.

QUESTION 8: . In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No." *

YES

If you answered “YES” to question 8, do not go to school or child care.

• You must isolate (stay home) and should not leave except to get tested or for a medical
emergency.
• Visit an assessment centre to get a COVID-19 test.
ϕ If you test negative (you do not have the virus), you can return to school/child care. ϕ If you test positive (you have the virus), you need to continue isolating and can return only
after you 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.
• Other people in your household must isolate until you test negative on a PCR test or are cleared
by your local public health unit. Household members who are fully immunized or previously
positive for COVID-19 in the last 90 days and have since been cleared are not required to isolate.
• Contact your school/child care provider to let them know about this result

If you answered “NO” to all questions, your child may go to school/child care. Follow your school/child care provider’s established process for letting staff know about this result.

Note: post immunization symptoms
• If you have received a COVID-19 vaccination in the last 48 hours and have mild fatigue, muscle
aches and/or joint pain that only began after immunization, and no other symptoms, you are to
wear a surgical/procedure mask for your entire time at work (indoors and outdoors).
• Your mask may only be removed to consume food or drink and you must remain at least two
metres away from others when your mask has been removed. If the symptoms worsen, continue
past 48 hours, or if you develop other symptoms, you should leave work immediately to self isolate and seek COVID-19 testing.

As per regular protocols, all sick individuals with any symptoms of illness should stay home, and
seek assessment from their regular health care provider if required. Individuals with severe symptoms
requiring emergency care should go to their nearest emergency department. If an individual develops
symptoms outside of the list above, the Public Health Unit may recommend other measures including
testing based on an assessment of the individual’s symptoms and exposure history

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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