Covid Health Screening Questionnaire (Kawartha Minor Hockey)

Covid Health Screening Questionnaire

Covid Health Screening Questionnaire to be completed each time before your child goes on the ice.

Are you currently experiencing?

Please answer Yes Or No. The Answer must be "No" to participate in any and all activity.

Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher) ^*

Required

Chills?^*

Required

Cough that's new or worsening? (continuous, more than usual)^*

Required

Barking cough, making a whistling noise when breathing (croup)?^*

Required

Shortness of Breath? (out of breath, unable to breathe deeply)^*

Required

Sore Throat?^*

Required

Difficulty Swallowing?^*

Required

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

Required

Lost sense of taste or smell?^*

Required

Pink eye? (conjunctivitis)^*

Required

Headache that is unusual or long lasting?^*

Required

Digestive issues? (nausea/ vomiting, diarrhea, stomach pain)^*

Required

Muscle Aches?^*

Required

Extreme tiredness that is unusual? (fatigue, lack of energy)^*

Required

Falling down often?^*

Required

For young children and infants: Sluggish or lack of appetite?^*

Required

Not applicable = N/A

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?

Yes or No

In the last 14 days, have you been in close physical contact with a person who is either currently sick with a cough, fever or difficulty breathing?

Yes or No

In the last 14 days, have you been in close physical contact with a person who has returned from outside Canada in the last 2 weeks?

Yes or No

Have you traveled outside of Canada in the last 14 days?

Yes or No

This questionnaire must be completed by each individual prior to participation in EACH on ice or off ice activity.

Please call 911 if you are experiencing:
1. Severe difficulty breathing (struggling for each breath, can only speak in single words).
2. Severe chest pain (constant or tightness or crushing sensation).
3. Feeling confused or unsure where you are.
4. Losing consciousness.

If you are in any of the following wish 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 conditions.)
4. Regularly going to a hospital or health care setting for a treatment. (For example, dialysis, surgery, cancer treatment.)

I agree to the terms and conditions stated above^*

Your Information

Please provide name for who the document is for (i.e. if player documents provide players name and provide parent/guardian info in the extra box provided)

Date ^*

Required

Players First Name^*

Required

Players Last Name^*

Required

Parent/Guardian For Name Above (First & Last) (if applicable)

Email Address^*

Required

Example: [email protected]

Phone Number^*

Required

Example: ###-###-####

Covid Health Screening Questionnaire (Kawartha Minor Hockey)

OMHA Digital Network

Are you currently experiencing?

Close Physical Contact means:

Your Information

Get Mobile!

Contact Us