COVID-19 Health Screen Questionnaire 21-22 (Flamborough Hockey Association Inc.)

Print COVID-19 Health Screen Questionnaire 21-22
*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. Each additional spectator must complete their own check in form
  4. Example: ###-###-####
  5. 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).
     

    ·       Fever and/or chills Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

    ·       Cough or barking cough (croup)Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

    ·       Shortness of breath Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

    ·       Decrease or loss of taste or smell Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

    ·       Muscle aches/joint pain, Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

    ·       Extreme tiredness, unusual fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

  6. 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.)

  7. 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.
     
  8. Example: [email protected] Your submission will be sent to this address.
Human Validation
Printed from flamboroughhockey.com on Tuesday, October 19, 2021 at 8:45 AM