Daily Screening Checklist
Daily Screening Checklist
*Please complete this screening form before entering STE St. Gabriel School Location.
*If the student is under 18 years of age, please have a parent or guardian complete the form.
*Receipt of this screening form is required for admittance to each of your lesson at STE St. Gabriel School location.
*This screening checklist will be updated to reflect any Government of Alberta and Alberta Health Services changes to questions and requirements.
*If you have answered "YES" to any of the questions below, please do not enter STE. Please go home and and use the AHS Online Assessment Tool to determine if testing is recommended. https://myhealth.alberta.ca/Journey/COVID-19/Pages/COVID-Self-Assessment.aspx
Today's Date
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/
MM
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DD
YYYY
Parent/Guardian Name
*
First
Last
Required if Parent/Guardian accompany the student
Child Name
*
First
Last
Child Name
First
Last
Email Address
*
Phone
-
(###)
-
###
####
1. Do you/your child have any new onset (or worsening) of the following symptoms:
*
Yes
No
Fever
Cough
Shortness of Breath / Difficulty Breathing
Sore throat
Chills
Painful swallowing
Running Nose / Nasal Congestion
Feeling unwell / Fatigued
Nausea / Vomiting / Diarrhea
Unexplained loss of appetite
Loss of sense of taste or smell
Muscle / Joint aches
Headache
Conjunctivitis (commonly known as pink eye)
2. Have you/your child or anyone in your household travelled outside of Canada in the last 14 days?
*
Yes
No
3. Have you/your child or anyone in your household had close unprotected contact (face-to-face contact within 2 meters/6 feet) with someone who has travelled outside of Canada in the last 14 days and who is ill with COVID-19 symptoms as listed above?
*
Yes
No
4. Have you/your child or anyone in your household been in close unprotected contact (face-to-face contact within two-meters) in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19?
*
Yes
No
5. Have you/your child or anyone in your household had close contact with a symptomatic** close contact of a confirmed case of COVID-19 in the last 14 days?
*
Yes
No
* "unprotected" means close contact without appropriate personal protective equipment.
** "ill/symptomatic" means someone with COVID-10 symptoms on the list above
