COVID-19 Active Surveillance Form
Glenashton Daycare Centre
1. Are you, your child or a family member experiencing fever, chills, cough or baking cough, shortness of breath, decrease or loss of taste or smell, experiencing sore throat or difficulty swallowing, nausea, vomiting and or diarrhea, tiredness, muscle aches.

All sick individual with any symptoms of illness (not included in the above list) should stay home and seek assessment from a health care provider

2. Does anyone in your household have one or more of the above symptoms and/or are waiting for test results after experiencing symptoms?

If your child is fully vaccinated* or have tested positive for COVID-19 in the last 90 days and been cleared, select “No”

3. Have you been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate?

If your child is fully vaccinated* or have tested positive for COVID-19 in the last 90 days and been cleared or public health has told you that you do not have to self-isolate, select “No”

4. In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

If you have since tested negative on a lab-based PCR test, select “No”

5. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?
6. Have you given or taken any fever reducing medications in the last 5 hours?

Thanks for submitting!

COVID-19 Screening Results
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