COVID-19 Health Screen Questionnaire (Flamborough Hockey Association)

TERMS AND CONDITIONS:
 
I acknowledge that I will submit this screener no earlier than 12 Hours of each scheduled session, prior to arriving at the arena.  I acknowledge that failure to do so may compromise my registration in the program.  

8.  DO NOT PARTICIPATE AND CONTACT 911 IF YOU HAVE ANY OF THE FOLLOWING:

• Severe difficulty breathing (struggling for each breath, can only speak in single words) • Severe chest pain (constant tightness or crushing sensation) • Feeling confused or unsure of where you are • Losing consciousness

9. CONSULT PHYSICIAN PRIOR TO ACTIVITY IF YOU HAVE:

• Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors) • Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder) • Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD) • Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

10. The answer to all the questions below must be “No” in order to participate in any and all activity (on-ice or off-ice).
 

·       Do you have a Fever? (Feeling hot to touch, temperature of 37.8C or higher) 

·       Chills

·       Cough that's new or worsening (continuous. More than usual)

·       Barking cough, making a whistle noise when breathing (croup)

·       Shortness of breath (out of breath, unable to breathe deeply) 

·       Sore throat

·       Difficulty swallowing

·       Runny nose, sneezing, or nasal congestion (not related to seasonal allergies or  other known causes or conditions) 

·       Lost sense of smell or taste

·       Pink Eye (conjunctivitis) 

·       Headache that is unusual or long lasting

·       Digestive Issues (nausea/vomiting, diarrhea, stomach pain) 

·       Muscle aches 

·       Extreme tiredness that is unusual (fatigue, lack of energy) 

·       Falling Down often

·       For young children and infants: sluggishness or lack of appetite

11. The answer  to all the questions below must be “No” in order to participate in any and all activity (on-ice or off-ice).

For the remaining questions, close physical contact means being less than 2 meters away in  the same  room, workspace, or  area for over 15 minutes or living in the same home

 

·       In the last 14 days, have you  been  in close physical contact with someone who  tested positive for COVID-19?

·       In the last 14 days, have you been in close physical contact with a person who either is currently sick with a new cough, fever, or difficulty breathing; Or returned from outside of Canada in the last  2 weeks? (This does not include essential workers who cross the Canada-US border regularly.)

·       Have you  travelled outside of Canada in the last 14 days? (This does not include essential workers who cross the Canada-US border regularly.)

12. If the individual has answered “Yes” to any of above questions, they are not permitted  to participate in any on-ice or off-ice activities with the Flamborough Hockey Association.