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COVID-19 Health Screening Form

First Name

Last Name

Phone Number

1. Does the student have any of the following new or worsening symptoms? Fever greater than 37.8°C, Cough, Difficulty breathing, Loss of taste or smell, Feeling unwell, muscle aches or tired, Stuffy or runny nose, Headache, Sore throat or pain swallowing, Nausea, vomiting or diarrhea.

Yes No

2. Does anyone in your household have one or more of the above symptoms?

Yes No

3. Has anyone in your household travelled outside of Canada in the last 14 days AND been required to quarantine?

Yes No

4. Has anyone in your household been notified as a close contact of someone with COVID-19 or been told to stay home and self-isolate?

Yes No

Digital Signiture

Confirm Digital Signiture

Signed On

If “YES” to Questions 1, 2,3,or 4: Stay home and follow Toronto Public Health advice

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901 Lawrence Avenue West
Toronto, ON M6A 1C3
Tel: 416-789-7011
Fax: 416-789-3951

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COVID-19 Health Screening Form

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