Fort Erie Co-operative Preschool's Daily Covid-19 Health Screening Checklist
In accordance with the Ministry of Health, Fort Erie Co-operative Preschool is required to have in place an enhanced screening process that must be completed daily in licensed chair care settings.

The responses you provide on this form will be used to determine your child's eligibility to enter the program today. The health of children, families, and the clients of essential workers who access this child care program depends on your honesty and accuracy when you complete this screening tool.

** Collection of Personal Information **

This applies to the personal information about the children in our care, their parents/legal guardians, their siblings, and others who are involved in their care (collectively, "The children in our care and their families").

Fort Erie Co-operative Preschool respects your privacy and we have a longstanding commitment to protecting the personal information of the children in our care and their families. For the purposes of this policy, "personal information" is defined as any identifiable information about the children in our care and their families, such as contact details, health information, living arrangements, background information, the child(ren)'s personal characteristics and behaviour styles.

Personal information is only collected, used, and disclosed by Fort Erie Co-operative Preschool in accordance with this Privacy Policy and the legal obligations imposed by the Personal Information Protection and Elecronic Documents Act (PIPEDA).
Date *
Child's Name *
Parent/Guardian Name *
1. Does this child have *any* of the following new or worsening symptoms? *
No. Continue.
Yes. No entry. The child must self-isolate at home immediately and then: A) Contact their health care provider, walk-in clinic, or online virtual clinic for guidance (this can be provided over the phone); or B) Contact a Niagara Health Covid-19 Assessment Centre to book an appointment for testing. This can be done online or by calling Niagara Health at 905-378-4647, ext. 42819; or C) Stay home for 10 days before returning to school
Runny nose
Difficulty breathing
Decrease/loss of smell or taste
Sore throat
Nausea, vomiting or diarrhea
Fatigue, lethargy or muscle aches
3. In the last 14 days, has your child travelled outside of Canada? *
4. In the last 14 days, has a public health unit identified your child as a "close contact" of someone who currently has Covid-19? *
5. Does your child or anyone in your household (including a sibling) currently have Covid-19 or is awaiting a Covid-19 test result? *
6. Has your child been directed by a health care provider, including a public health official, to isolate? *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy