COVID-19 screening

Little Lambs Home Daycare Agency

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COVID-19 Screening

This form is required to be completed in its entirety prior to visiting our office

COVID-19 Office Screening

* Indicates required field

Date *

Name *

First

Last

Phone Number *

contact information is required for contact tracing purposes.

You are a (select one) *

Little Lambs employee Child Care Provider Visitor

When will you be at our office? *

Morning Afternoon All day

Are you currently or within the past 14 days experiencing any of the following symptoms: fever, cough, difficulty breathing, sore throat/trouble swallowing, runny nose or red eyes, loss of taste or smell, nausea, vomiting or diarrhea *

yes no

answer yes, only if the symptoms you're experiencing are not related to a diagnosed medical condition such as asthma or allergies.

In the past 14 days have you been informed to self-isolate or tested positive for COVID-19? *

yes no

Have you been in close contact with someone who is exhibiting any of the above symptoms, has been informed to self-isolate, or has confirmed COVID-19 in the past 14 days? *

yes no

Have you or someone you're in close contact with travelled outside of Canada in the past 14 days? *

yes no

If you are a visitor please comment the reason for your visit. *

Submit

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