SANS Covid Checklist
Parents/ Guardians/ Staff must fill out this questionnaire to decide of the child/staff should attend today. By completing this form, you consent to the collection of this information for the sole purpose of supporting public health contact tracing efforts in the event that an attendee tests positive.

Our goal is to minimize the risk of infection for our staff and children.
THANK YOU FOR YOUR UNDERSTANDING AND COOPERATION
Child's First Name and Last Name Initial *
Date *
MM
/
DD
/
YYYY
Full name of DROP OFF person *
Full name of PICK UP person *
Does the person attending have any of the BELOW SYMPTOMS *
YES
NO
FEVER
COUGH
SHORTNESS OF BREATH/ DIFFICULTY BREATHING
SORE THROAT
CHILLS
PAINFUL SWALLOWING
RUNNY NOSE/ NASAL CONGESTION
FEELING UNWELL/ FATIGUED
NAUSEA/ VOMITING/ DIARRHEA
UNEXPLAINED LOSS OF APPETITE
LOSS OF SENSE OF TASTE OR SMELL
MUSCLE/ JOINT ACHES
HEADACHE
CONJUNCTIVITIS (PINK EYE)
Has your child TRAVELLED OUTSIDE OF CANADA in the last 14 DAYS? *
Has your CHILD had CLOSE UNPROTECTED CONTACT (face to face contact within 6 feet) in the last 14 DAYS with SOMEONE WHO IS ILL WITH COUGH OR FEVER? *
Has your CHILD had CLOSE UNPROTECTED CONTACT (face to face contact within 6 feet) in the last 14 DAYS with SOMEONE WHO IS BEING INVESTIGATED OR CONFIRMED TO BE A CASE OF COVID-19? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy