YMCA of HBB

*Child's Temperature:

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 C/100 F or higher
Cough (more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing)
Shortness of breath (dyspnea, out of breath, unable to breathe deeply, wheeze, that is worse than usual if chronically short of breath)
Decrease or loss of smell or taste (new olfactory or taste disorder)
None of the Above

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.

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)
Stuffy nose and/or runny nose
Headache that is new and persistent, unusual, unexplained, or long-lasting
Nausea, vomiting and/or diarrhea
Fatigue, lethargy, muscle aches or malaise (general feeling of bein unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained
None of the Above

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.

3. Has your child travelled outside of Canada in the past 14 days?:

Yes
No

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)?:

Yes
No

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

Yes
No

If the individual answers "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 the health care provider for further advice.

Result

*Results:

Pass
Fail

Staff Performing Screening

*I performed the required health screening for this child:

Staff Name

SACC Brantford Health Screening

Child's Information

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.:

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.:

3. Has your child travelled outside of Canada in the past 14 days?:

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)?:

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

Result

Staff Performing Screening

Careers

Volunteers