COVID-19 Pre-Screening Form

Your Name (must be legal parent/guardian of participant)

Participant Name

1. Does your child have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higherCough - (more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing). Not related to other known causes or conditions (e.g., asthma, reactive airway)Shortness of breath - (dyspnea, out of breath, unable to breathe deeply, wheeze, that is worse than usual if chronically short of breath). Not related to other known causes or conditions (e.g., asthma)Decrease or loss of smell or taste - (new olfactory or taste disorder). Not related to other known causes or conditions (e.g., nasal polyps, allergies, neurological disorders)None of the above

2. Does your child have any of the following new or worsening symptoms? Symptoms should not be chronic or related to other known causes or conditions.

Sore throat - (painful swallowing or difficulty swallowing). Not related to other known causes or conditions (e.g., post nasal drip, gastroesophageal reflux)Stuffy nose and/or runny nose - (nasal congestion and/or rhinorrhea). Not related to other known causes or conditions (e.g., seasonal allergies, returning inside from the cold, chronic sinusitis unchanged from baseline, reactive airways)Headache that is new and persistent, unusual, unexplained, or long-lasting Not related to other known causes or conditions (e.g., tension-type headaches, chronic migraines)Nausea, vomiting and/or diarrhea - Not related to other known causes or conditions (e.g. transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effect of medication)Fatigue, lethargy, muscle aches or malaise - (general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained. Not related to other known causes or conditions (e.g., depression, insomnia, thyroid dysfunction, anemia)None of the above

3. Have you travelled outside of Canada in the last 14 days?

YesNo

4. Has your child been identified as a close contact of someone who is confirmed as having COVID-19 by your local public health unit (or from the COVID Alert app if they have their own phone)?

YesNo

5. Has your child been directed by a health care provider including public health official to isolate?

YesNo

Results of Screening Questions

If you answered “YES” to any of the symptoms included under question 1:

• Your child should stay home to isolate immediately.
• Contact your child’s health care provider for further advice or assessment, including if your
  child needs a COVID-19 test or other treatment.

If you answered “YES” to only one of the symptoms included under question 2:

• Your child should stay home for 24 hours from when the symptom started.
• If the symptom is improving, your child may return to school/child care when they feel well
  enough to do so. A negative COVID-19 test is not required to return.
• If the symptom persists or worsens, contact your child’s health care provider for further
  advice or assessment, including if your child needs a COVID-19 test or other treatment.

If you answered “YES” to two or more of the symptoms included under question 2:

• Your child should stay home to isolate immediately.
• Contact your child’s health care provider for further advice or assessment, including if your
  child needs a COVID-19 test or other treatment.

If you answered "YES" to question 3, 4 or 5:

• Your child should stay home to isolate immediately and follow the advice of public health.
• If your child develops symptoms, you should contact your local public health unit or your
  child’s health care provider for further advice.

If you answered “NO and None of the above” to all the questions, your child may come to the studio!