COVID-19 Health Screen Questionnaire (Flamborough Hockey Association)

Print COVID-19 Health Screen Questionnaire
*FORM TO BE FILLED OUT FOR EVERY ICE TIME-NO EARLIER THAN 12 HOURS PRIOR TO SCHEDULED ICE-TIME
  1. 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.  
    Your email receipt copy of this submission must be shown at the arena door prior to entry.
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  3. Example: ###-###-####
  4. 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

  5. 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.)

  6. 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.
     
  7. Example: [email protected] Your submission will be sent to this address.
Human Validation
Printed from flamboroughhockey.com on Thursday, October 29, 2020 at 9:23 PM