Manor Park Community Council - MPCC Child Participant Screening (2022)

Active Screening Questionnaire

for Children in Recreation Programs

Active Screening is a health review of your child. Completing Active Screening daily BEFORE participation in a recreational program is a mandate of the Ministry of Health and Ottawa Public Health.

It helps everyone remain safe and healthy!

Information collected will only be used by the Manor Park Community Council for the administration and management of children's arts and sports programming. Information will only be shared as legally required.

Child

First name *

Last name *

×

Parent

First name *

Last name *

Email *

1. In the last [5, 10] days has your child experienced any of these symptoms? *

•If fully vaccinated, use 5 days
•If not fully vaccinated OR immune compromised, use 10 days.

Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours and should seek assessment from their health care provider if needed.

Household members of individuals with any of the below symptoms should stay home at the same time as the person who is sick, regardless of vaccination status.

If your child is symptomatic and tested negative for COVID-19 on a single PCR test or two rapid antigen tests (RAT) taken 24 hours apart, and symptoms have been improving for 24 hours, you may answer “no” to all symptoms.

Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

Fever and/or chills Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills. Cough or barking cough (croup) Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions you already have) Shortness of breath Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have) Decrease or loss of taste or smell Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have None of the above apply

2. In the last [5, 10] days has your child experienced any of these symptoms? *

•If fully vaccinated, use 5 days
•If not fully vaccinated OR if immune compromised, use 10 days.

Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

Sore throat or difficulty swallowing Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions they already have) Runny or stuffy/congested nose Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions they already have Headache Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions they already have) If they received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “No.” Extreme tiredness Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions they already have) If they received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue and/or mild muscle aches/joint pain that only began after vaccination, select “No.” Muscle aches or joint pain If they received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue and/or mild muscle aches/joint pain that only began after vaccination, select “No.” Nausea, vomiting and/or diarrhea Not related to irritable bowel syndrome, anxiety, or other known causes or conditions they already have None of the above apply.

3. In the last [5, 10]days has your child tested positive for COVID-19? *

This includes a positive COVID-19 test result on a lab-based PCR test, rapid antigen test or home-based self-testing kit.
•If fully vaccinated, use 5 days
•If not fully vaccinated OR if immune compromised, use 10 days.

Yes No

4. Do any of the following apply? *

•Your child lives with someone who is currently isolating because of a positive COVID-19 test
•Your child lives with someone who is currently isolating because of COVID-19 symptoms
•Your child lives with someone who is waiting for COVID-19 test results

If the individual isolating has not tested positive for COVID-19 and only has one of these symptoms: sore throat or difficulty swallowing, runny or stuffy/congested nose, headache, extreme tiredness, muscle aches or joint pain, nausea, vomiting and/or diarrhea, select “No.”

Yes No

5. Has your child been identified, or self-identify, as a “close contact” of someone who currently has COVID-19 and been advised to self-isolate? *

If public health guidance provided to you has advised you that your child does not need to self-isolate, select “No.”

Yes No

6. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

This can be because of an outbreak or contact tracing.

Yes No

7. Do any of the following apply? *

•In the last 14 days, have your child has travelled outside of Canada and was told to quarantine
•In the last 14 days, have your child has travelled outside of Canada and was told to not attend school/child care
•In the last 14 days, someone your child lives with has returned from travelling outside of Canada and is isolating while awaiting results of a COVID-19 test.

Yes No

Results of screening questions:
If you answered “YES” to ANY question, your child may not attend a program, enter or arrive at any MPCC affiliated locations (Manor Park Public School, Manor Park Community Centre, 1805 Gaspe Ave.)

Click here to review the guidance in regards to isolating and testing requirements.
If your child is a program participant - please stay home.

If you answered “NO” to all questions, your child may attend the program.

I confirm: *

The information I am about to submit is valid and true.

Yes No

Electronic signature *

Please sign your name inside the box

×