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COVID-19 Surveillance Form
Date (DD/MM/YYYY):
Name of School/Child Care Facility:
Contact Information (Fill out all applicable sections) Name: Grade/
Class: Date of Birth (DD/MM/YYYY): Sex:
Name of Parent/Guardian:
Contact Info (phone/email):
Called in sick ☐ or Sent home sick ☐
Date Excluded from School/Child Care Facility______________________________ (DD/MM/YYYY)
Alternate Diagnosis on File? Yes☐ No☐
Additional Comments:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please send the completed form to [email protected] or by fax to 807-468-3914. Personal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact the health unit at 800-830-5978 or see the privacy statement on our web-site at www.nwhu.on.ca
Symptoms (check all that apply) Date of First Symptom (DD/MM/YYYY):
Fever (≥37.8 C) ☐ Headache ☐ Sore Throat ☐ Dry cough (new) ☐ Fatigue/Weakness ☐ Difficulty Swallowing ☐ Worsening of chronic cough ☐ Nausea/Vomiting ☐ Difficulty Breathing ☐ Runny nose/sneezing ☐ Diarrhea ☐ Abdominal Pain ☐ Congestion ☐ Pink Eye ☐ Other: ☐ Muscle aches ☐ Rash ☐
