Hitherfield School

Health Screening Form (Parents)

Hitherfield School COVID Screening Questions

Please note you must do one submission for each Hitherfield School student in your family.
Student Name*
Temperature Unit:*
- Degrees Celsius
- Degrees Fahrenheit
Temperature*
The temperature should be in Degrees Celsius
Temperature*
The temperature should be in Degrees Fahrenheit
Has the child and / or anyone in the household been diagnosed or is awaiting test results / under investigation for COVID-19 in the past 14 days?*
- YES
- NO
Has the child and/ or anyone in the household had close contact with a known or suspected case of COVID-19 in the past 14 days?*
- YES
- NO
Has the child and / or anyone in the household travelled outside of Canada in the last 14 days?*
- YES
- NO
Has the child and / or anyone in the household been informed by public health or another authority to self-isolate or quarantine in the past 14 days?*
- YES
- NO
Has your child had any medication for fever reduction in the 8 hours prior to school arrival time?*
- YES
- NO
In the past 48 hours:
1. Has your child had 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 99.5 degrees Fahrenheit or greater)
- YES
- NO
Cough*
(more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing) and not related to other known causes or conditions (e.g asthma, reactive airway)
- YES
- NO
Shortness of Breath*
(dyspnea, out of breath, unable to breathe deeply, wheeze that is worse than usual if chronically short of breath). Not related to other known causes or conditions (e.g., asthma)
- YES
- NO
Decrease or loss of smell or taste*
Decrease or loss of smell or taste (new olfactory or taste disorder). Not related to other known causes or conditions (e.g., nasal polyps, allergies, neurological disorders)
- YES
- NO
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). Not related to other known causes or conditions (e.g., post nasal drip, gastro-esophageal reflux)
- YES
- NO
Stuffy nose and/or runny nose*

Not related to other known causes or conditions (e.g., seasonal allergies, returning inside from the cold, chronic sinusitis unchanged from baseline, reactive airways)
- YES
- NO
Headache*

that is new and persistent, unusual, unexplained, or long-lasting and not related to other known causes or conditions (e.g., tension-type headaches, chronic migraines)
- YES
- NO
Nausea, vomiting and/or diarrhea*

Not related to other known causes or conditions (e.g., transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effect of medication)
- YES
- NO
Fatigue, lethargy, muscle aches or malaise*

(general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained. Not related to other known causes or conditions (e.g., depression, insomnia, thyroid dysfunction, anemia)
- YES
- NO
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.

If you answered “YES” to only one of the symptoms included under question 2:

• Your child should stay home for 48 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.

If you answered “NO” to all the questions, your child may go to school.
Emergency Contact*
Name Phone Relationship
Parent Signature*
Parent Name*
Parent Email*
Date
Do you want to submit the health screening questionnaire for another child?*
- Yes
- No
When you click the submit button, it will redirect to the same form in order to submit the questionnaire for another child.

Hitherfield School | 2439 10th Sideroad, Campbellville, Ontario, L0P1B0 | 905-854-0890 | info@hitherfieldschool.com

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Hitherfield School

Hitherfield School COVID Screening Questions

In the past 48 hours:

1. Has your child had 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.

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