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. Submitting this Questionnaire to the Manor Park Community Council (MPCC) makes it easy for you to comply.
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.
Screening Questions (all questions must be answered)
1. In the last 14 days, has your child or anyone they live with travelled outside of Canada?
YES NO
If exempt from quarantine requirements, for example, an essential worker who crosses the Canada-US border regularly for work, select “No”.
2. Has a doctor, health care provider, or public health unit told you that your child should currently be isolating (staying at home)?
YES NO
This can be because of an outbreak or contact tracing.
3. In the last 14 days, has your child been identified as a “close contact” of someone who currently has COVID-19?
YES NO
4. In the last 14 days, have you or a member of your household received a COVID Alert exposure notification?
YES NO
If they have since gone for a covid-19 test and received a negative test result, select “No”.
5. Does your child have one or more of the following symptoms?
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Continuous; more than usual; making a whistling noise when breathing; not related to other known causes or conditions (for example, asthma, post-infectious reactive airways)
Out of breath; unable to breathe deeply; not related to other known causes or conditions (for example, asthma)
Not related to other known causes or conditions (for example, allergies, neurological disorders)
Painful swallowing, not related to other known causes or conditions (for example, seasonal allergies, acid reflux)
Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)
Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)
Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps)
Fatigue; lack of energy; not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction, sudden injury)
6. Is someone that your child lives with currently experiencing any COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
YES NO
Results of Screening Questions
If you answered “YES” to any of these question your child may not attend the program today.
Please contact Ottawa Public Health at (613)580-6744 for guidance
If you answered “NO” to all questions, your child may attend the program.
By signing below, you are confirming you have answered NO to all questions and your child is cleared to attend the program.
Please accept all conditions.