FMM Schools

Covid-19 Daily Health Screening Questionnaire

Covid-19 Daily Health Screening Questionnaire
Overview

This checklist applies for all children, as well as all students who attend kindergarten through Grade 12, including high school students over 18. Children should be screened every day by completing this checklist before going to school, childcare or other activities. Children may need a parent or guardian to assist them to complete this screening tool.

If your child has traveled outside Canada in the last 14 days, follow the Government of Canada Travel, Testing, Quarantine and Borders instructions, including any requirements for exempt travelers related to attending high-risk environments.

If within the last 10 days, your child has been notified by Public Health that they are a case3 of COVID-19, they are required to isolate as per Public Health instructions.
Student Name*
Temperature Unit*
- Degrees Celsius
- Degrees Fahrenheit
Student Temperature (°C)*
Student Temperature (°F)*
Screening Questions
1. Has your child been a household contact of a case of COVID-19 in the last 14 days?*
A household contact: a person who lives in the same residence as the case OR who has been in frequent, long-duration, close-range interaction with a case of COVID-19. For example, siblings, someone who slept over, or someone who provided direct physical care to the child.
- Yes
- No
If the answer is “YES” AND they are NOT fully immunized:

Child should stay home and NOT attend school, childcare and/or other activities for 14 days from the last day of exposure and monitor for symptoms. If your child has symptoms, proceed to question 2.

If the answer is “NO” to question 1, proceed to question 2
2. Does the child have any new onset (or worsening) of the following core symptoms:
Fever*
Temperature of 38 degrees Celsius or higher
- Yes
- No
Cough*
Continuous, more than usual, not related to other known causes or conditions such as asthma
- Yes
- No
Shortness of breath*
Continuous, out of breath, unable to breathe deeply, not related to other known causes or conditions such as asthma
- Yes
- No
Loss of sense of smell or taste*
Not related to other known causes or conditions like allergies or neurological disorders
- Yes
- No
If the child answered “YES” to any symptom in question 2:

The child is required to isolate for 10 days from onset of symptoms as per the current CMOH Order OR receive a negative COVID-19 test and feel better before returning to activities.

Use the AHS Online Assessment Tool or call Health Link 811 to arrange for testing and to receive additional information on isolation.

If the child answered “NO” to all of the symptoms in question 2:

• Proceed to question 3.
3. Does the child have any new onset (or worsening) of the following other symptoms:
Chills*
Without fever, not related to being outside in cold weather
- Yes
- No
Sore throat/painful swallowing*
Not related to other known causes/conditions, such as seasonal allergies or reflux
- Yes
- No
Runny nose/congestion*
Not related to other known causes/conditions, such as seasonal allergies or being outside in cold weather
- Yes
- No
Feeling unwell/fatigued*
Lack of energy, poor feeding in infants, not related to other known causes or conditions, such as depression, insomnia, thyroid dysfunction or sudden injury
- Yes
- No
Nausea, vomiting and/or diarrhea*
Not related to other known causes or conditions, such as anxiety, medication or irritable bowel syndrome
- Yes
- No
Unexplained loss of appetite*
Not related to other known causes or conditions, such as anxiety or medication
- Yes
- No
Muscle/joint aches*
Not related to other known causes or conditions, such as arthritis or injury
- Yes
- No
Headache*
Not related to other known causes or conditions, such as tension-type headaches or chronic migraines
- Yes
- No
Conjunctivitis (commonly known as pink eye)*
- Yes
- No
If the child answered “YES” to ONE symptom in question 3:
- Keep your child home and monitor for 24 hours.
- If their symptom is improving after 24 hours, they can return to school and activities when they feel well enough to go. Testing is not necessary.
- If the symptom does not improve or worsens after 24 hours (or if additional symptoms emerge), use the AHS Online Assessment Tool or call Health Link 811 to check if testing is recommended
If the child answered “YES” to TWO OR MORE symptoms in question 3:
- Keep your child home.
- Use the AHS Online Assessment Tool or call Health Link 811 to determine if testing is recommended.
- Your child can return to school and activities once their symptoms go away as long as it has been at least 24 hours since their symptoms started.
If the child answered “NO” to all questions:
- Your child may attend school, child care and/or other activities.
Please Note:
If your child is experiencing any symptoms from the lists above, do not bring them to visit continuing care or acute care facility for 10 days from when symptoms started/until symptoms resolve (whichever is longer), unless they receive a negative COVID-19 test result and feel better.
Adult Temperature (°C)*
The temperature of the parent who drops off the child.
Adult Temperature (°F)*
The temperature of the parent who drops off the child.
Signature*
Name*
Parent Email*
Date*
Date Format: MM slash DD slash YYYY
Do you want to submit the health screening questionnaire for another child?*
- Yes
- No
When you click the submit button, it will redirect to the same form in order to submit the questionnaire for another child.
*Face-to-face contact within 2 metres. A health care worker in an occupational setting wearing the recommended personal protective equipment is not considered to be a close contact.

** ' Ill/Symptomatic' means someone with COVID-19 symptoms on the list above

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FortMcMurray Alberta

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FMM Schools

Covid-19 Daily Health Screening Questionnaire

Screening Questions

2. Does the child have any new onset (or worsening) of the following core symptoms:

3. Does the child have any new onset (or worsening) of the following other symptoms:

Please Note:

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