U11 A Covid-19 Health Screening Form (Caledon Female Hockey Association)
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U11 A Covid-19 Health Screening Form
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U11 A Covid-19 Health Screening Form
This form MUST be filled out for Participants (Players), Members of the Coaching Staff, and any Parents/Guardians entering the rink EACH and EVERY time there is an ice activity.
Participant Information
Please note: This Health Screening questionnaire has been developed based on the Ontario Ministry of Health Self-Assessment Tool (June 17, 2020).
LAST Name
*
FIRST Name
*
Date and Time of Ice Activity
*
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Location of Ice Activity
*
Albion Bolton Community Centre
Caledon East
Inglewood
Mayfield
Is this screening for a Participant (Player), Member of the Coaching Staff, or Parent/Guardian?
*
Participant (Player)
Member of the Coaching Staff
Parent/Guardian
Are you currently experiencing any of these issues? Call 911 if you are.
Severe difficulty breathing (struggling for each breath, can only speak in single words)
*
Yes
No
Severe chest pain (constant tightness or crushing sensation)
*
Yes
No
Feeling confused or unsure of where you are
*
Yes
No
Losing consciousness
*
Yes
No
If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating.
1. 70 years old or older
2. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)
3. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition)
4. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)
I am not a member of any of these risk groups.
*
Are you experiencing any of these symptoms?
The answer must be NO in order to participate in each on-ice activity.
Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher)
*
Yes
No
Chills
*
Yes
No
Cough that’s new or worsening (continuous, more than usual)
*
Yes
No
Barking cough, making a whistling noise when breathing (croup)
*
Yes
No
Shortness of breath (out of breath, unable to breathe deeply)
*
Yes
No
Sore throat
*
Yes
No
Difficulty swallowing
*
Yes
No
Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)
*
Yes
No
Lost sense of taste or smell
*
Yes
No
Pink eye (conjunctivitis)
*
Yes
No
Headache that’s unusual or long lasting
*
Yes
No
Digestive issues (nausea/vomiting, diarrhea, stomach pain)
*
Yes
No
Muscle aches
*
Yes
No
Extreme tiredness that is unusual (fatigue, lack of energy)
*
Yes
No
Falling down often
*
Yes
No
For young children and infants: sluggishness or lack of appetite
Yes
No
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.
If an individual has answered “Yes” to any of these questions, they are not permitted to participate in any on-ice or off-ice activities.
In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?
*
Yes
No
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?
*
Yes
No
Have you travelled outside of Canada in the last 14 days?
*
Yes
No
Human Validation
Check The Box
*
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