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.

    If participant feels sick or not well, even with symptoms not listed in this screening tool, please do not attend your scheduled ice time and speak with a health care provider if necessary. If you have any pre-existing health condition that compromises or weakens your immune system please consult your physician prior to participation.
      
    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 entered on this same line, separated by comma, one submission per player/participant.
  4. Example: ###-###-####
  5. 8.  DO NOT PARTICIPATE AND CONTACT A HEALTH CARE PROVIDER OR 911 IF NECESSARY 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. 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. 10.  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 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?

    - Have you been identified as a close contact by a Public Health Department, School, Childcare Centre and directed to isolate?

    - In the last 14 days, have you travelled outside of Canada and been told to quarantine or told to not attend school/childcare?
    (per the federal quarantine requirements; For those under 12 who are not vaccinated: if you are exempt from federal quarantine because you travelled with a fully vaccinated companion, you must not go to school/child care for 14 days)

    - Has a doctor, health care provider, or public health unit told you that you should currently be isolating at home (this can be because of an outbreak or contact tracing)?

    - In the last 10 days have you tested positive on a rapid antigen test or home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select No

     
  7. 11. 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 Thursday, August 11, 2022 at 2:34 PM