Unionville Skating Club
COVID-19 school and child care screening

Students and children must screen for COVID-19 every day before going to school
or child care. Parents/guardians can fill this out on behalf of a child.
Ice Session *
Location *
Today's Date and Session Time
MM
/
DD
/
YYYY
Time
:
First and Last Name *
Phone Number
Phone Number format : 416-123-4567
1. In the last 14 days, has the student/child or anyone they live with travelled outside of Canada?
If exempt from quarantine requirements (for example, an essential worker who crosses the Canada-US border regularly for work), select “No.”
Clear selection
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.
Clear selection
3. In the last 14 days, has the student/child been identified as a “close contact” of someone who currently has COVID-19?
Clear selection
4. In the last 14 days, has the student/child received a COVID Alert exposure notification on their cell phone?
If they already went for a test and got a negative result, select “No.”
Clear selection
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.
Fever and/or chills
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Clear selection
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 they already have)
Clear selection
Shortness of breath
Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have)
Clear selection
Decrease or loss of taste or smell
Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have
Clear selection
Sore throat or difficulty swallowing
Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions they already have)
Clear selection
Runny or stuffy/congested nose
Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions they already have
Clear selection
Headache
Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions they already have)
Clear selection
Nausea, vomiting and/or diarrhea
Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have
Clear selection
Extreme tiredness or muscle aches
Unusual, fatigue, lack of energy, poor feeding in infants (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions they already have)
Clear selection
6. Is someone that the student/child lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
Clear selection
❗ 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 they 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.
• Contact your school/child care provider to let them know about this result
❗ If you answered “YES” to any of the symptoms included under question 5 or question 6 do not go to school or child care.
• The student/child must isolate (stay home) and not leave except to get tested or for a
medical emergency.
• If you answered “YES” to question 5, talk with a doctor/health care provider to get advice or
an assessment, including if the student/child need a COVID-19 test.
• If you answered “YES” to question 6, the student/child can return to school or child care after
the individual gets a negative COVID-19 test result, or is cleared by your local public health unit,
or is diagnosed with another illness.
• Siblings or other people in your household must stay at home until the student/child showing
symptoms or individual tests negative, or is cleared by your public health unit, or is diagnosed
with another illness.
• 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 because they seem to be healthy and have not been exposed to COVID-19. Follow your school/child care provider’s established process for letting staff know about this result (if applicable).
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