Today's date is:
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Today D-M-Y
NEW: As of March 8th CHEO is moving to passive screening (using signage) for patients and families. We encourage you to continue to use this screening tool prior to your visit to complete your screen and receive guidance should you, your child, or a household member have symptoms.
Please Note:
Why are you planning to come to CHEO?
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Visiting admitted patient(s)
Appt at 401 Smyth Road CHEO location (including but not limited to Ambulatory care visits, MDU, Day Care Surgery, Diagnostic Imaging, Outpatient Lab, Dev and Rehab clinic visits, Children's Treatment Centre appointments, Genetic clinic visits and on-site schools (CHEO School/Preschool))
Vendor, contractor, delivery personnel, External Learner
In-home Appointment/in-home visit
Off-site programs/ Off-site services (E.g. Renfrew, Cornwall, St. Laurent)
Your first Name
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Your last name:
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Your Email AddressA confirmation will be sent to this email so please ensure that you have access to this email address
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Your phone number
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"Visiting Admitted Patient" Screening Questions
Please specify area:
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4 EAST 4 NORTH 4 WEST 5 EAST 5 NORTH 6 EAST 6 NORTH INTENSIVE CARE (ICU) NEONATAL INTENSIVE CARE (NICU)
Who are you coming to visit (First Name & Last Name)?
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Who is being screened today? (select all that apply)
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Please Note: At this time visitors are not permitted at CHEO. If an exception has been made for you to visit by your clinical team, please screen in person at one of our screening b Is the patient you are visiting under isolation precautions?
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Yes
No
Unknown
End of Admitted Patient Info
Which company/organization are you from?
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What is the reason for your visit to CHEO?
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Please specify area(s).
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How many caregiver(s) are attending the appointment?
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One
Two
Please Note:only one caregiver (a parent, guardian, or family representative) is allowed to accompany children and youth while attending appointments at all CHEO location(s). An exception is required to have 2 caregivers visit. If an exception has not already been granted by your clinical team please contact your clinic to discuss this request prior to your visit.
Visitor Screening Questions for Admitted Patients
Are you fully vaccinated?
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Yes
No
Have you or anyone in your household had close contact with a confirmed case of COVID-19 in the past 10 days, tested positive for COVID-19 in the last 10 days or has been instructed to self-isolate?
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Yes
No
In the past 10 days have you or anyone in your household had any (one) of the following symptoms?Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of taste or smell Unexplained fatigue/lethargy/malaise/muscle aches Sore throat Runny nose/nasal congestion Headache Conjunctivitis Decreased appetite
AND/OR
In the past 48 hours have you or anyone in your household had any (one) of the following symptoms?
Nausea/vomiting, diarrhea * must provide value
Yes
No
Have you or anyone in your household travelled outside of Canada in the last 14 days and been instructed to self-isolate by Canadian Border Services (Customs)?
* must provide value
Yes
No
Result- Visitor Screening for Admitted Patients
View equation Caregiver Screening Questions for admitted patients
If the individual being screened is immunocompromised, please have the individual screen using an isolation period of 20 days instead of 10 days.
Cancer chemotherapy Untreated HIV infection with CD4 T lymphocyte count < 200 Combined primary immunodeficiency disorder Those taking prednisone >20 mg/day (or equivalent) for more than 14 days and taking other immune suppressive medications. Caregivers and patients are now screened as a household. These questions should be asked for every patient and or caregiver attending CHEO.
Are you fully vaccinated?
* must provide value
Yes
No
Have you or anyone in your household had close contact with a confirmed case of COVID-19 in the past 10 days, tested positive for COVID-19 in the last 10 days or has been instructed to self-isolate?
* must provide value
Yes
No
In the past 10 days have you or anyone in your household had any (one) of the following symptoms?Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of taste or smell Unexplained fatigue/lethargy/malaise/muscle aches Sore throat Runny nose/nasal congestion Headache Conjunctivitis Decreased appetite
AND/OR
In the past 48 hours have you or anyone in your household had any (one) of the following symptoms?
Nausea/vomiting, diarrhea * must provide value
Yes
No
Have you or anyone in your household travelled outside of Canada in the last 14 days and been instructed to self-isolate by Canadian Border Services (Customs)?
* must provide value
Yes
No
Result- Caregiver Screening for admitted
View equation Caregiver(s)/Patient(s) Screening questions for Out Patient appt:
If the individual being screened is immunocompromised, please have the individual screen using an isolation period of 20 days instead of 10 days.
Cancer chemotherapy Untreated HIV infection with CD4 T lymphocyte count < 200 Combined primary immunodeficiency disorder Those taking prednisone >20 mg/day (or equivalent) for more than 14 days and taking other immune suppressive medications. What is the patient's full name?
* must provide value
Are you fully vaccinated?
* must provide value
Yes
No
Have you or anyone in your household had close contact with a confirmed case of COVID-19 in the past 10 days, tested positive for COVID-19 in the last 10 days or has been instructed to self-isolate?
* must provide value
Yes
No
In the past 10 days have you or anyone in your household had any (one) of the following symptoms?Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of taste or smell Unexplained fatigue/lethargy/malaise/muscle aches Sore throat Runny nose/nasal congestion Headache Conjunctivitis Decreased appetite
AND/OR
In the past 48 hours have you or anyone in your household had any (one) of the following symptoms?
Nausea/vomiting, diarrhea * must provide value
Yes
No
Have you or anyone in your household travelled outside of Canada in the last 14 days and been instructed to self-isolate by Canadian Border Services (Customs)?
* must provide value
Yes
No
Results- Caregiver(s)/Patient(s) Screening for Outpatient
View equation Vendor/Contract/Delivery Screening Questions:
If the individual being screened is immunocompromised, please have the individual screen using an isolation period of 20 days instead of 10 days.
Cancer chemotherapy Untreated HIV infection with CD4 T lymphocyte count < 200 Combined primary immunodeficiency disorder Those taking prednisone >20 mg/day (or equivalent) for more than 14 days and taking other immune suppressive medications. Are you fully vaccinated?
* must provide value
Yes
No
Have you or anyone in your household had close contact with a confirmed case of COVID-19 in the past 10 days, tested positive for COVID-19 in the last 10 days or has been instructed to self-isolate?
* must provide value
Yes
No
In the past 10 days have you or anyone in your household had any (one) of the following symptoms?Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of taste or smell Unexplained fatigue/lethargy/malaise/muscle aches Sore throat Runny nose/nasal congestion Headache Conjunctivitis Decreased appetite
AND/OR
In the past 48 hours have you or anyone in your household had any (one) of the following symptoms?
Nausea/vomiting, diarrhea * must provide value
Yes
No
Have you or anyone in your household travelled outside of Canada in the last 14 days and been instructed to self-isolate by Canadian Border Services (Customs)?
* must provide value
Yes
No
Results- Vendor, contractor, delivery personnel
View equation In-Home Appt Screening Questions:
If the individual being screened is immunocompromised, please have the individual screen using an isolation period of 20 days instead of 10 days.
Cancer chemotherapy Untreated HIV infection with CD4 T lymphocyte count < 200 Combined primary immunodeficiency disorder Those taking prednisone >20 mg/day (or equivalent) for more than 14 days and taking other immune suppressive medications. Are you fully vaccinated?
* must provide value
Yes
No
Have you or anyone in your household had close contact with a confirmed case of COVID-19 in the past 10 days, tested positive for COVID-19 in the last 10 days or has been instructed to self-isolate?
* must provide value
Yes
No
In the past 10 days have you or anyone in your household had any (one) of the following symptoms?Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of taste or smell Unexplained fatigue/lethargy/malaise/muscle aches Sore throat Runny nose/nasal congestion Headache Conjunctivitis Decreased appetite
AND/OR
In the past 48 hours have you or anyone in your household had any (one) of the following symptoms?
Nausea/vomiting, diarrhea * must provide value
Yes
No
Have you or anyone in your household travelled outside of Canada in the last 14 days and been instructed to self-isolate by Canadian Border Services (Customs)?
* must provide value
Yes
No
Results- In Home Appt
View equation Are you fully vaccinated?
* must provide value
Yes
No
Off Site Appt Screening Questions: off-site clinics, day programs and community schools including section 23 schools.
If the individual being screened is immunocompromised, please have the individual screen using an isolation period of 10 days instead of 5 days.
Cancer chemotherapy Untreated HIV infection with CD4 T lymphocyte count < 200 Combined primary immunodeficiency disorder Those taking prednisone >20 mg/day (or equivalent) for more than 14 days and taking other immune suppressive medications. Which location are you visiting?
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Thurston Site Cornwall Site Kanata Site Renfrew Site Industrial Site St. Laurent Site Youth Net CTC/Development & Rehab Montreal Rd Site CHAL Other
Have you or anyone in your household had close contact with a confirmed case of COVID-19 in the past 5 days, tested positive for COVID-19 in the last 5 days or has been instructed to self-isolate?
* must provide value
Yes
No
In the past 10 days have you or anyone in your household had any (one) of the following symptoms?Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of taste or smell Unexplained fatigue/lethargy/malaise/muscle aches Sore throat Runny nose/nasal congestion Headache Conjunctivitis Decreased appetite
AND/OR
In the past 48 hours have you or anyone in your household had any (one) of the following symptoms?
Nausea/vomiting, diarrhea * must provide value
Yes
No
Have you or anyone in your household travelled outside of Canada in the last 14 days and been instructed to self-isolate by Canadian Border Services (Customs)?
* must provide value
Yes
No
Results- Offsite location
View equation For information on CHEO's masking guidelines please click here: Face masks at CHEO
Thank You for completing your screen.
Thank You!
Green Alert: Caregiver(s) for admitted Patient
Are you using one of CHEO's screening Kiosks (IPAD) to complete your screen?
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Yes, I am using CHEO's screening kiosk IPAD at the main entrance
No (e.g. screening from home etc.)
Patients full name:
* must provide value
Are you fully vaccinated?
* must provide value
Yes
No
Have you or anyone in your household had close contact with a confirmed case of COVID-19 in the past 10 days, tested positive for COVID-19 in the last 10 days or has been instructed to self-isolate?
* must provide value
Yes
No
In the past 10 days have you or anyone in your household had any (one) of the following symptoms?Fever and/or chills New onset of cough or worsening chronic cough Shortness of breath Decrease or loss of taste or smell Unexplained fatigue/lethargy/malaise/muscle aches Nauseau/vomiting, diarrhea Sore throat Runny nose/nasal congestion Abdominal pain Headache Conjunctivitis Decreased appetite
* must provide value
Yes
No
Have you or anyone in your household travelled outside of Canada in the last 14 days and been instructed to self-isolate by Canadian Border Services (Customs)?
* must provide value
Yes
No
Result- On-Site Screen
View equation
You are clear to enter the building. Have a nice day!
Based on one or more of your responses you are not cleared to proceed to your appointment. Please go to the 4th booth for further direction. Green Alert: Caregiver(s) for admitted Patient ACTIVATED
View equation Red Alert: Caregiver(s) for admitted patient
Yellow Alert: Caregiver(s)-- Visiting admitted patient under precautions
Green Alert: Visitor for admitted patient
Red Alert: Visitor for admitted patient
Green: Caregiver(s)/Patient(s) Outpatient
Blue- Unvaccinated Caregiver
Red: Caregiver(s)/Patient(s) outpatient
Red: Vendor/Contract/Delivery
Green: Vendor/Contract/Delivery
