RSOSC Daily Health Screening Questionnaire (Child)

Attention Please!!!

Parents or guardians must fill out this questionnaire to decide if their child should enter the program each day. It MUST be submitted to us BEFORE your child attends the program. If you are unable to fill out the form and we are not able to verify with you have been able to complete the screening on your child, your child may be denied entrance into the program for that day. Our Goal is to minimize the risk of infection to our staff and children. Thank you for understanding and cooperation.

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* 1. What is your child/ren's names? (If you have more than one child attending our program, you will only need to fill in the form once, but please make sure that you include both of your children's names)

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* 2. Which RSOSC location is your child/ren at ?

Richard Secord School Location

Enjoy Life Church Location

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* 3. What school is your child attending?

Richard Secord School

Greenfield School

Westbrook School

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* 4. Please document the date or time of filling out this questionnaire.

Date / Time

Date

Time

AM/PM

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* 5. Do you, or your child attending the program, have any of the below symptoms ?

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 (i.e Pink Eye)

None of above symptoms listed are present in myself or my child/ren

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* 6. Have you, or anyone in your household, traveled outside of Canada in the last 14 days?

Yes

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* 7. Have you or your children attending the program had close unprotected * contact (face-to-face contact within 2 metres/6 feet) with someone who is being investigated or confirmed to be a case of COVID-19? (Unprotected means close contact without appropriate personal protection equipment)

Yes

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* 8. Have you or anyone in your household been in close unprotected* contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? (Unprotected means close contact without appropriate personal protection equipment)

Yes

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* 9. Please note if your child has any symptoms listed above or have answered "Yes" to any above questions, your child will NOT BE ABLE TO ATTEND the program at this time. If your child has specific health concerns that we should be aware of, please clarify below. Thank you.