COVID-19 Screening Tool for Children in School and Child Care - To be completed daily for each family

School Name: Village Montessori School
School Address: Inglewood United Church, 15673 McLaughlin Rd., Inglewood, ON, L7C 1M9

This daily screening is required as per Daily Active Screening for Covid-19 Policy. This form must be filled for each family daily - siblings need submit only one form. Select multiple classes if siblings go to separate classes. Temperature must be recorded for each child entering the centre. If, for either child entering the centre, you answer YES to any of these questions, record the name of the child below the check box. Close contact is being coughed or sneezed on or being within 2 meters of an individual with COVID-19 symptoms for 15 minutes.

Parent/Guardian’s Name (First, Last)
Child 1:
Name (First, Last):
Child 2:
Name (First, Last):
Q1: Does your child(ren) have ANY of the following new or worsening COVID-19 symptoms?*
  • fever (37.8°C or higher) and/or chills
  • cough or barking cough (croup)
  • shortness of breath
  • decrease or loss of taste or smell
  • sore throat or difficulty swallowing
  • runny or stuffy/congested nose
  • headache that is unusual or long lasting
  • nausea, vomiting and/or diarrhea
  • unusual or extreme tiredness or muscle aches

Q2: Did your child(ren) or anyone they live with** travel outside Canada in the last 14 days?

Q3: Have your child(ren) been identified as a close contact of someone who is confirmed as having COVID-19 by your local public health unit?

Q4: Have your child(ren) been directed by a health care provider, including public health official, to isolate or stay home?

Q5: Did your child(ren) have close contact with anyone (including household members) with COVID-19 symptoms in the last 14 days who has not been tested or is awaiting COVID-19 test results?


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

  • Your child should stay home to isolate immediately and be tested for COVID-19.
  • Contact your child’s health care provider if you are unsure testing or another treatment is needed.

If the individual answered “YES” to question 2:

  • Remain in isolation until the end of the 14-day quarantine after return to Canada. Test if any COVID-19 symptom develops.

If the individual answered “YES” to question 3:

  • Isolate for 14 days after last exposure to the COVID-19 case or as directed by Public Health. Follow Public Health’s guidance for testing.

If the individual answered “YES” to question 4:

  • Isolate or stay home for the recommended period of time by Public Health, even if the individual has tested negative.

If the individual answered “YES” to question 5:

  • Isolate until the person with COVID-19 symptoms in the household receives a negative test or an alternative diagnosis by a health care provider.

Parents/guardians are advised to obtain information on symptoms, COVID-19 testing and self-isolation by seeing a health care provider, visiting or contacting Peel Public Health at 905-799-7700(Caledon: 905-584-2216).