You must stay home (DO NOT GO TO SCHOOL) if you answer YES to any of the questions below:

Consult with York Public Health website to determine your next step if you answer “YES”
York Public Health – COVID19

    Daily COVID19 Screening Form

    Students must screen for COVID-19 every day before going to child care. Parents/guardians can fill this out on behalf of a child.

    Screening Date
    Student Name


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

    Cough or barking cough (croup)
    Continuous, more than usual, making a whistling noise when breathing, not related to other known causes or conditions (for example, asthma, postinfectious reactive airways):

    Shortness of breath
    Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma):

    Decrease or loss of smell or taste
    Not related to other known causes or conditions (for example, allergies, neurological disorders):

    Sore throat or difficulty swallowing
    Painful swallowing, not related to other known causes or conditions (for example, seasonal allergies, acid reflux):

    Runny or stuffy/congested nose
    Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather):

    Headache that’s unusual or long lasting
    Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines):

    Nausea, vomiting and/or diarrhea
    Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps):

    Extreme tiredness that is unusual or muscle aches
    Fatigue, lack of energy, poor feeding in infants, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction, sudden injury):

    Travel
    Have they travelled outside of Canada in the last 14 days?

    Close Contact
    In the last 14 days, has a public health unit identified them as a close contact of someone who currently has COVID-19?:

    Stay at home
    Has a doctor, health care provider, or public health unit told them/you that they should currently be isolating (staying at home)?:

    COVID Alert
    In the last 14 days, have they received a COVID Alert exposure notification on their cell phone?

    Close Contact
    In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?
    If public health has advised you that you do not need to self-isolate, select “No.”

    Anyone you live with
    Is anyone you live with currently experiencing any new COVID-19 symptoms (listed below) and/or waiting for test results after experiencing symptoms?
    Children (17 years old or younger): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, nausea, vomiting and/or diarrhea
    Adults (18 years old or older): fever and/or chills, cough or barking cough, shortness of breath, decrease or loss of taste or smell, tiredness, muscle aches
    If the person got a COVID-19 vaccine in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

    Type your name below to certify the undersigned confirm the correctness of this screening form: