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COVID-19 Screening for Staff and Visitors

    Location:

    Name of person filling out this form:


    Screening Questions

    1. In the last [5, 10] days have you experienced any of these symptoms?

    Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours and should seek assessment from their health care provider if needed. Household members of individuals with any of the below symptoms should stay home at the same time as the person who is sick, regardless of vaccination status.

    If you are symptomatic and tested negative for COVID-19 on a single PCR test or two rapid antigen tests (RAT) taken 24 hours apart, and symptoms have been improving for 24 hours, you may answer “no” to all symptoms.

    Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

    Fever and/or chills

    Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills.


    Cough or barking cough (croup)

    Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions you already have)


    Shortness of breath

    Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)


    Decrease or loss of taste or smell

    Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have


    Sore throat or difficulty swallowing

    Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)


    Runny or stuffy/congested nose

    Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have


    Headache

    Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)
    If you received a COVID-19 and/or flu vaccination in the last 48 hours and is experiencing a mild headache that only began after vaccination, select “No.”


    Extreme Tiredness

    Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions you already have)
    If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue and/or mild muscle aches/joint pain that only began after vaccination, select “No.”


    Muscle achesor joint pain

    If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue and/or mild muscle aches/joint pain that only began after vaccination, select “No.”


    Nausea, vomiting and/or diarrhea

    Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have


    2. In the last [5, 10]days have you tested positive for COVID-19?

    This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test or home-based self-testing kit.

    3. Do any of the following apply

    • You live with someone who is currently isolating because of a positive COVID-19 test

    • You live with someone who is currently isolating because of COVID-19 symptoms

    • You live with someone who is waiting for COVID-19 test results

    If the individual isolating has not tested positive for COVID-19 and only has one of these symptoms: sore throat or difficulty swallowing, runny or stuffy/congested nose, headache, extreme tiredness, muscle aches or joint pain, nausea, vomiting and/or diarrhea, select “No.”

    4. Have you been identified as a “close contact” of someone who currently has COVID-19 and been advised to self-isolate?

    If public health guidance provided to you has advised you that you do not need to self-isolate, select “No.”

    5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

    This can be because of an outbreak or contact tracing.

    6. Do any of the following apply?

    • In the last 14 days, have you travelled outside of Canada and were told to quarantine

    • In the last 14 days, have you travelled outside of Canada and were told to not attend school/child care

    • In the last 14 days, someone you live with has returned from travelling outside of Canada and is isolating while awaiting results of a COVID-19 test.

    Public Health Ontario – Contact Tracing

    Answering these questions is optional.This information will only be used by Public Health officials for contact tracing. All information will be deleted in 28 days.



    IMPORTANT: Please read the information below before submitting the form.

    Results of screening questions

    If you answered “YES” to ANY question, you cannot go to school or child care. Contact your school/child care provider to let them know that you will not be attending school today. See below for isolation and testing requirements.

    NOTE: When the option of [5, 10] days is listed:

    • If you are fully vaccinated, use 5 days
    • If you are not fully vaccinated OR if you are immune compromised, use 10 days

    If you answered “YES” to any of the symptoms listed under question 1, do not go to school or child care.

    • You must isolate (stay home) and not leave except to get tested or for a medical emergency.
    • If the you are not tested, and if:
      • You are fully vaccinated you must isolate for 5 days from when symptoms started and stay in isolation until your symptoms have been improving for 24 hours (or 48 hours after nausea, vomiting and/or diarrhea symptoms), whichever is longest.
      • You are not fully vaccinated OR if you are immune compromised you must isolate for 10 days from when the symptoms started and stay in isolation until your symptoms have been improving for 24 hours (or 48 hours after nausea, vomiting and/or diarrhea symptoms), whichever is longest.
    • If testing is available:
      • If a single PCR test or rapid antigen test is positive, you should follow the guidance above “if you are not tested”
      • If a single PCR test is negative or two rapid antigen tests (RATs) collected 24-48 hours apart are both negative, you may return to school/child care when your symptom(s) have been improving for 24 hours (48 hours for nausea, vomiting and/or diarrhea).
    • Household members must stay home at the same time as you, whether they are fully vaccinated or not.

    If you answered “YES” to any of the symptoms listed under question 2, do not go to school or child care.

    • If you have experienced only one of these symptoms in the last [5, 10] days you must stay home until the symptom has been improving for at least 24 hours (48 hours for nausea, vomiting and/or diarrhea).
    • If you have experienced two or more of these symptoms in the last [5, 10] days you must stay home.
      • If you are not tested and:
        • You are fully vaccinated you must isolate for 5 days from when symptoms started and stay in isolation until their symptoms have been improving for 24 hours (48 hours for nausea, vomiting and/or diarrhea), whichever is longest.
        • You are not fully vaccinated OR if you are immune compromised you must isolate for 10 days from when the symptoms started and stay in isolation until your symptoms have been improving for 24 hours (48 hours for nausea, vomiting and/or diarrhea), whichever is longest.
    • If testing is available:
      • If a single PCR test or a rapid antigen test is positive, you should follow the guidance above, “if you are not tested”.
      • If a single PCR test or two rapid antigen tests (RATs) collected 24-48 hours apart are both negative, you may return to school/child care when your symptoms have been improving for at least 24 hours (48 hours for nausea, vomiting and/or diarrhea).
    • Household members must stay home at the same time as you, whether they are fully vaccinated or not.

    NOTE: If you also answered “YES” to question 1, follow question 1 guidance for next steps, including testing, if available.

    If you answered “YES” to question 3, do not go to school or child care

    • You must isolate (stay home) and only leave for a medical emergency.
    • If you are fully vaccinated you must isolate for 5 days from when symptoms started or from when you tested positive for COVID-19 (whichever was first) and stay in isolation until your symptoms have been improving for 24 hours (or 48 hours after nausea, vomiting and/or diarrhea symptoms), whichever is longest.
    • If you are not fully vaccinated OR if you are immune compromised you must isolate for 10 days from when the symptoms started or from when you tested positive for COVID-19 (whichever was first) and stay in isolation until your symptoms have been improving for 24 hours (or 48 hours after nausea, vomiting and/or diarrhea symptoms), whichever is longest.
    • Household members must stay home at the same time as you, whether they are fully vaccinated or not.

    If you answered “YES” to question 4, do not go to school or child care.

    • You must isolate (stay home) while there is anyone in the home who is isolating because of symptoms, a positive COVID-19 result, or is waiting for a COVID-19 test result. You should only leave home for a medical emergency.
    • All household members must stay home at the same time as the household member who has COVID-19 symptoms or is a positive COVID-19 case, whether they are fully vaccinated or not.

    If you answered “YES” to question 5 or 6, do not go to school or child care.

    • You must isolate (stay home) and not leave except to get tested or for a medical emergency.
    • If you develop symptoms, follow isolation guidance found under results to ”If you answered “YES” to any of the symptoms listed under question 1 do not go to school or child care.” and/or “If you answered “YES” to any of the symptoms listed under question 2, do not go to school or child care” depending on the symptoms you are experiencing.
    • If you are isolating because you were identified as a close contact of someone who currently has COVID-19 and were advised to isolate, or because of an outbreak or contact tracing, other people in your household can go to school, child care or work, but must not leave the home for other, non-essential reasons.

    If you answered “YES” to question 7, do not go to school or child care.

    • You must follow federal guidelines for individuals who have travelled internationally, including not going to school/child care for 14 days after their arrival and getting tested as per federal requirements.
    • If you have been directed to quarantine, you must stay home for 14 days and not leave except to get tested or for a medical emergency. For more information on federal requirements for travellers, please see the Government of Canada’s website.
    • If someone you live with is isolating following return from travelling outside of Canada and received a take-home PCR test at the airport, is symptomatic following international travel OR is awaiting test results, you must stay home until the individual has received a negative PCR test result.
    • If you develop symptoms, follow isolation guidance found under results to “If you answered “YES” to any of the symptoms listed under question 1 do not go to school or child care.” and/or “If you answered “YES” to any of the symptoms listed under question 2, do not go to school or child care” depending on the symptoms you are experiencing.

    If you answered “NO” to all questions, you may go to school/child care. Follow your school/child care provider’s established process for letting them know about this result.

    • As per regular protocols, all sick individuals with any symptoms of illness should stay home and seek assessment from their regular health care provider if required.
    • Individuals with severe symptoms requiring emergency care should go to their nearest emergency department.
    • If an individual develops symptoms outside of the list above, the Public Health Unit may recommend other measures including testing based on an assessment of the individual’s symptoms and exposure history.