COVID-19 Active Screening Form for Staff - Region of Peel
COVID-19 Active Screening Form for Staff (to be completed daily)Name of Child Care/EarlyON Centre: ____________________________Address of Child Care/EarlyON Centre: ___________________________Staff Member’s Name (First, Last): ____________________________ INSTRUCTIONSThe screening process outlined in the Daily Screening for COVID-19 of Persons Entering EYCC Settings policy will be followed by all staff responsible for conducting screening. Screening staff must complete/verify one monthly screening form for each staff member. If YES was answered for any of the questions below, do not permit the staff person to enter the child care/EarlyON centre (see Pages 4-6 for details). Symptomatic staff are strongly recommended to get tested for COVID-19 before returning to work. In general, you are a close contact if at least one of the following apply to you: You had close, prolonged, and/or unprotected contact with someone who has COVID-19 while they were infectious.You had direct contact with the infectious body fluids of a person with COVID-19 (e.g., coughed or sneezed on).Peel Public Health or another public health unit identified you as a close contact.Anyone who is sick and has any symptoms of illness, including those not listed in the screening form, should stay home and seek assessment from their health care provider if needed. For more information on symptoms, COVID-19 testing and self-isolation, consult with a health care provider, visit or contact Peel Public Health at 905-799-7700 (Caledon: 905-584-2216).DateQ1: Are you currently experiencing any of these symptoms*:fever (37.8°C or higher) and/or chillscough or barking coughshortness of breathdecrease or loss of smell or tastemuscle aches/joint pain that is unusual or long lastingextreme tiredness that is unusual Q2: In the last 14 days, have you travelled outside of Canada and been advised to quarantine as per the federal quarantine requirements?**Q3: In the last 10 days, has a public health unit identified you as a “close contact” of someone who currently has COVID-19?Q4: Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)?Q5: In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?Q6: Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?Q7: In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?Q8: In the last 10 days, has anyone in your household tested positive on a rapid antigen test or a home-based self-testing kit?*Symptoms are new, worsening, and not related to other known causes or medical conditions. **Exemptions to the federal quarantine requirements include essential workers who travel across the Canada-US border regularly for work and fully vaccinated individuals who meet the exemption requirements.1? Yes ? No? Yes ? No? Yes ? No? Yes ? No? Yes ? No? Yes ? No? Yes ? No? Yes ? No2? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No3? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No4? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No5? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No6? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No7? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No8? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No9? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No10? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No11? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No12? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No13? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No14? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No15? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No16? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No17? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No18? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No19? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No20? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No21? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No22? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No23? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No24? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No25? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No26? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No27? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No28? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No29? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No30? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? No31? Yes ? No? Yes ? No? Yes ? No? Yes ? No ? Yes ? No? Yes ? No? Yes ? No? Yes ? Noleft10795COVID-19 ScreeningNotice with Respect to the Collection, Use and Disclosure of Personal Health Information The information pertaining to your COVID-19 Screening is being collected, used and disclosed under the authority of the Health Protection and Promotion Act R.S.O 1990 c.H.7 and will be retained, used, disclosed and disposed of in accordance with all applicable municipal, federal and provincial laws and regulations governing the collection, use, disclosure and disposal of information including the Municipal Freedom of Information and Protection of Privacy Act R.S.O. 1990 c.M.56 and the Personal Health Information Protection Act 2004 S.O. 2004 c.3.This information will be used by Peel Public Health to investigate the occurrence of COVID-19 in the Region of Peel, provide case management, follow-up with close contacts to assess the risk to others, program planning and evaluation. If you test positive for COVID-19, your result may be disclosed to your child care/EarlyON provider to reduce the risk of spreading the virus in a child care/EarlyON setting. Any questions, regarding this collection, use or disclosure may be directed to the Medical Officer of Health, Peel Public Health, 7120 Hurontario Street, P.O. Box 669 RPO Streetsville, Mississauga, Ontario, L5M 2C2, 905-791-7800.020000COVID-19 ScreeningNotice with Respect to the Collection, Use and Disclosure of Personal Health Information The information pertaining to your COVID-19 Screening is being collected, used and disclosed under the authority of the Health Protection and Promotion Act R.S.O 1990 c.H.7 and will be retained, used, disclosed and disposed of in accordance with all applicable municipal, federal and provincial laws and regulations governing the collection, use, disclosure and disposal of information including the Municipal Freedom of Information and Protection of Privacy Act R.S.O. 1990 c.M.56 and the Personal Health Information Protection Act 2004 S.O. 2004 c.3.This information will be used by Peel Public Health to investigate the occurrence of COVID-19 in the Region of Peel, provide case management, follow-up with close contacts to assess the risk to others, program planning and evaluation. If you test positive for COVID-19, your result may be disclosed to your child care/EarlyON provider to reduce the risk of spreading the virus in a child care/EarlyON setting. Any questions, regarding this collection, use or disclosure may be directed to the Medical Officer of Health, Peel Public Health, 7120 Hurontario Street, P.O. Box 669 RPO Streetsville, Mississauga, Ontario, L5M 2C2, 905-791-7800.RESULTS OF SCREENING QUESTIONSIf the individual answered “YES” to any of the symptoms included under Question 1: Individual should stay home to isolate immediately and be tested for COVID-19 even if they are fully vaccinated or tested positive for COVID-19 in the last 90 days and have since been cleared.Individual should contact their health care provider if they are unsure if testing or another treatment is needed. Note: If the individual received a COVID-19 vaccination in the last 48 hours and is only experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, then they would answer NO to this question. The individual must wear a surgical/procedure mask for their entire time at the child care setting. Their mask may only be removed to consume food or drink and they must remain at least two metres away from others when their mask has been removed. If the symptoms worsen, continue past 48 hours, or if they develop other symptoms, they should leave the child care setting immediately to self-isolate and seek COVID-19 testing.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.Note: Individuals who are exempt from the federal quarantine requirements include essential workers who travel across the Canada-US border regularly for work and fully vaccinated individuals who meet exemption requirements. These individuals would answer NO to this question. If the individual answered “YES” to Question 3:Isolate for 10 days after last exposure to the COVID-19 case or as directed by Public Health. Follow Public Health’s guidance for testing. Asymptomatic individuals who are fully vaccinated or have tested positive for COVID-19 in the last 90 days and have since been cleared do not need to self-isolate unless required by Peel Public Health. These individuals would answer NO to this question. Testing for COVID-19 is still recommended for fully vaccinated individuals. Individuals who have previously tested positive should get tested only if symptoms of COVID-19 develop or if directed by Public Health to do so. Individuals with immunocompromising conditions are still required to self-isolate and should get tested.Symptomatic individuals must self-isolate and should get tested for COVID-19 even if they are fully vaccinated or previously positive for COVID-19 in the last 90 days and have since been cleared.Fully vaccinated: Individuals are considered fully vaccinated 14 days after receiving the last dose of a Health Canada approved COVID-19 vaccine (a second dose of a 2-dose vaccine, or a single dose of a 1-dose vaccine) or any combination of these vaccines.Individuals are also considered fully vaccinated 14 days after receiving:one or two doses of a COVID-19 vaccine not approved by Health Canada, followed by one dose of a COVID-19 mRNA vaccine approved by Health Canada (e.g., Pfizer or Moderna); orthree doses of any COVID-19 vaccine not approved by Health Canada. If the fully vaccinated individual is immunocompromised, they should continue to self-isolate after being exposed to a person who has COVID-19, even if they are fully vaccinated. If they have questions about their immunocompromised status, they should speak to their health care provider.If the individual answered “YES” to Question 4: Isolate for the recommended period of time by Public Health, even if the individual has tested negative. If the individual answered “YES” to Question 5: The individual should get tested and isolate until they receive their results. Asymptomatic individuals who are fully vaccinated or have tested positive for COVID-19 in the last 90 days and have since been cleared do not need to self-isolate unless required by Public Health. These individuals would answer NO to this question. Testing for COVID-19 is still recommended for fully vaccinated individuals. Individuals who have previously tested positive should get tested only if symptoms of COVID-19 develop or if directed by Public Health to do so. Note: Individuals with immunocompromising conditions should get tested and isolate until they receive their results.If the individual answered “YES” to Question 6:Isolate until the person with COVID-19 symptoms receives a negative test or an alternative diagnosis by a health care provider. Note: If the person experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is only experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, the staff member would answer NO to this question.Individuals who are fully vaccinated or have tested positive for COVID-19 in the last 90 days and have since been cleared are not required to stay at home while the symptomatic person awaits test results. These individuals would answer NO to this question. Note: Individuals with immunocompromising conditions are still required to stay at home while the symptomatic person awaits test results.If the individual answered “YES” to Question 7:Isolate and do not leave home except to get tested or for a medical emergency.Get tested for COVID-19 with a lab-based PCR test. For more information on where to get tested, visit: If the individual has since tested negative on a lab-based PCR test, the individual would answer NO to this question.If the individual tested positive on a PCR test, the individual will need to continue isolating and can return only after they are cleared by their local public health unit.Other people in the individual's household must isolate until the individual tests negative on a PCR test or are cleared by their local public health unit. Asymptomatic household members who are fully vaccinated or previously positive for COVID-19 in the last 90 days and have since been cleared are not required to isolate. If the individual answered “YES” to Question 8:Isolate and do not leave home except to get tested or for a medical emergency.If the household member has since tested negative on a lab-based PCR test, the individual would answer NO to this question.The individual can return to the Child Care/EarlyON setting after the household member who tested positive on a rapid antigen test or home-based self-testing kit tests negative on a PCR test.Asymptomatic individuals who are fully vaccinated or have tested positive for COVID-19 in the last 90 days and have since been cleared are not required to stay at home while the person who tested positive on a rapid antigen test or home-based self-testing kit awaits test results. These individuals would answer NO to this question. Note: Individuals with immunocompromising conditions are still required to stay at home while the person who tested positive on a rapid antigen test or home-based self-testing kit awaits test results. ................
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