LWS Faculty Screening Agreement
To be completed each Sunday. Please read and sign this form weekly.

***Note: if you have children at the school, please fill out their screening forms separately.
Your Last Name *
Your First Name *
At which screening station will you be entering the school? *
Daily Screening
We are currently recommending daily use of the Ontario School Screening Tool to help you through the process of screening each day before coming to school, and understanding what to do if symptoms are identified. 
covid-19.ontario.ca/school-screening/
Instructions
It is a requirement that you complete a self-assessment screen each day prior to arriving at school.

If you are experiencing one or more of the following symptoms (that are new, worsening, and not related to other known causes or medical conditions), and/or answers yes to one or more of the additional questions, you have a “positive screening result” and must stay home.

SYMPTOMS:

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 other known causes or conditions (for example, asthma, post-infectious reactive airways)

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

Decrease or loss of taste or smell - Not related to other known causes or conditions (for example, allergies, neurological disorders)

Sore throat or difficulty swallowing - Painful swallowing, not related to other known causes or conditions (for example, seasonal allergies, acid reflux)

Runny or stuffy/congested nose - Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

Headache that’s unusual or long lasting - Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)

Nausea, vomiting, and/or diarrhea - Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps)

Extreme tiredness that is unusual - Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction)

Pink eye - conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes)

Muscle aches that are unusual or long lasting - not related to other known causes or conditions (for example, a sudden injury, fibromyalgia)

Falling down often - for older people

ADDITIONAL QUESTIONS:

● Have you travelled outside of Canada in the past 14 days?
● In the last 14 days, has a public health unit identified you as a “close contact” of someone who currently has COVID-19?
● Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
● In the last 14 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, your answer is “No.”
Positive Screening Process
If you answered “YES” to ANY of the symptoms:
• You should stay home to isolate immediately.
• Contact your health care provider for further advice or assessment, including if you need a COVID-19 test or other treatment.

If you answered "YES" to any of the ADDITIONAL QUESTIONS:
• You should stay home to isolate immediately and follow the advice of public health.
• If you develop symptoms, you should contact your local public health unit or your health care provider for further advice.

RETURNING TO SCHOOL
Please follow the recommendations of the Ontario School Screening Tool for employees: covid-19.ontario.ca/school-screening/
I hereby agree to complete a daily assessment prior to arriving at school and will follow the guidelines and recommendations as set out in the Ontario COVID-19 School and Child Care Screening tool for employees. *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of London Waldorf School. Report Abuse