Temporary Attestation Staff (January 2021)

Attestation for Staff return to school location / child care centre following illness, exclusion or self-isolation

Please complete this form to document that it is safe for you to return to the child care program at Waterdown District Children’s Centre, or to a School Age school location.

Staff Name*

First Last

Telephone*

(Add extension only if necessary)

Email*

Primary Location*

WDCC (215 Parkside Dr)
Allan A. Greenleaf (WDHS)
Mary Hopkins
Guy B. Brown

Program*

Toddler
Preschool
Kindergarten
Grades 1 - 8

Group Name

(if known)

Date of Exclusion*

I failed the active screening or was sent home from the child care centre / school on this date.

Date of Return*

I have met the criteria and would like to return to the child care centre or before / after school program on this date.

I have been for a COVID-19 test, with negative results, and it has been a minimum of 24 hours since I was first excluded and no longer present symptoms (other than of a professionally diagnosed alternate medical condition).*

Yes
No

A Covid-19 test results and a doctor's note must be provided in the case of a professionally diagnoses alternate medical condition that presents symptoms similar to COVID-19.

Please stay at home until 24 hours have passed since being excluded and no longer present symptoms (other than of a professionally diagnosed alternate medical condition).

Choose Return Criteria

Chose the one that applies best. All other screening criteria must also be passed. *Symptoms (other than diagnosed alternate medical condition) may not be suppressed by medications (i.e. Tylenol, antihistamines, etc.). **A negative COVID-19 test result must be presented to administration in advance.

I had a negative COVID-19 test** after starting to feel sick or was excluded. I no longer present symptoms*, meet other screening criteria (i.e. it has been 14 days since travel or close contact, etc.) and and have not been directed to isolate further.
I had a negative COVID-19 test** and I have been diagnosed by a healthcare professional and told I have a medical condition that causes the symptoms observed. (A doctor's note describing the condition and anticipated symptoms is required to return.) I no longer present symptoms*, meet other screening criteria and have not been directed to isolate further. (Add details below.)
I had a negative COVID-19 test** and I have been diagnosed by a healthcare professional and have been told the illness is caused by a diagnosis (medical reason) other than COVID-19 (a doctor's note describing the condition and anticipated symptoms is required to return). I no longer presents symptoms*, meet other screening criteria and have not been directed to isolate further.
A child or another adult in my household no longer or has one or more of the symptoms* related to COVID-19 and were not or are no longer required to isolated I meet other screening criteria and have not been directed to isolate further.
Myself, or a child or another adult in my household had travelled outside the country more than 14 days ago. I do not present symptoms*, meet other screening criteria and have not been directed to isolate further.
Myself, or a child or another adult in my household was in close physical contact with someone who had COVID-19 and it has been 14 days since the date of exposure. I meet other screening criteria and I have been directed by Hamilton Public Health that it is safe to return.
Myself or a child or another adult in my household was told to stay home and self-isolate more than 14 days ago. I meet other screening criteria and I have been directed by Hamilton Public Health that it is safe to return.

Details*

Please add any details here that may aid our understanding of the conditions that led to exclusion and are now met for re-inclusion of your child.

Signature*

Phone

This field is for validation purposes and should be left unchanged.

Temporary Attestation Staff (January 2021)

Attestation for Staff return to school location / child care centre following illness, exclusion or self-isolation

Programs

Important Links

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