U22 Covid-19 Health Screening Form (Orangeville Tigers Girls Hockey)

Provincial Lockdown Ends Hockey!

Print U22 Covid-19 Health Screening Form

This form MUST be filled out EACH and EVERY time you come to the rink.

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^*
Alder REDAlder GREENTonyATonyB
Is this screening for a Participant (Player), Member of the Coaching Staff, or Parent/Guardian?^*
Participant (Player)Member of the Coaching StaffParent/GuardianOther (Sibling, etc.)

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)^*
YesNo
Severe chest pain (constant tightness or crushing sensation)^*
YesNo
Feeling confused or unsure of where you are^*
YesNo
Losing consciousness^*
YesNo

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) ^*
YesNo
Chills^*
YesNo
Cough that’s new or worsening (continuous, more than usual)^*
YesNo
Barking cough, making a whistling noise when breathing (croup) ^*
YesNo
Shortness of breath (out of breath, unable to breathe deeply) ^*
YesNo
Sore throat^*
YesNo
Difficulty swallowing^*
YesNo
Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)^*
YesNo
Lost sense of taste or smell^*
YesNo
Pink eye (conjunctivitis) ^*
YesNo
Headache that’s unusual or long lasting^*
YesNo
Digestive issues (nausea/vomiting, diarrhea, stomach pain) ^*
YesNo
Muscle aches^*
YesNo
Extreme tiredness that is unusual (fatigue, lack of energy)^*
YesNo
Falling down often^*
YesNo
For young children and infants: sluggishness or lack of appetite
YesNo

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?^*
YesNo
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?^*
YesNo
Have you travelled outside of Canada in the last 14 days?^*
YesNo