2020 Health Screening - U11 Group B (Dorchester Minor Hockey Association)
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2020 Health Screening - U11 Group B
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2020 Health Screening - U11 Group B
U11 Group B - Coach: Matt Jansel
For players, officials, parents associated with this team ONLY. Those associated with other groups, find the form set up for that group: "Health Screening" in website's menu bar, pick desired team from drop-down list.
This questionnaire must be completed by
each
individual
prior to attendance at each on-ice or off-ice activity.
ONTARIO HOCKEY FEDERATION - Health Screening Questionnaire
Are you currently experiencing any of these issues? Call 911 if you are.
1. Severe difficulty breathing (struggling for each breath, can only speak in single words)
2. Severe chest pain (constant tightness or crushing sensation)
3. Feeling confused or unsure of where you are
4. Losing consciousness
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) The answer to all questions must be “No” in order to participate in any and all activity.
Participant
Contact, Team and Event information for the Participant or Spectator screened in this form. EACH PERSON NEEDS THEIR OWN FORM. EXAMPLE, ONE PLAYER AND ONE PARENT WATCHING MEANS TWO FORMS ARE NEEDED.
Last Name
*
Person filling out this form or on whose behalf the form is filled out
First Name
*
Person filling out this form or on whose behalf the form is filled out
Phone Number
*
For Contact Tracing if needed. Format ###-###-####
Participant Type
*
Select One...
Player
Coach or Team Staff
Spectator
Game or Association Official
Event Type
*
Practice
Event Date
*
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RadDatePicker
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Event Time
*
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Time picker
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HH:mm am/pm format to type directly
The answer to all screening questions must be "No" in order to participate in any and all activity. If one or more questions are answered "Yes", please advise your team's representative immediately and
DO NOT ENTER THE ARENA
.
Participant Screening
Are you currently experiencing any of these symptoms?
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. (Answer "No" for not applicable.)
*
Yes
No
Contacts & Recent Travel
For the remaining questions, close physical contact means: Being less than 2 metres 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?
*
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 breationg - OR - Returned from outside of Canada in the last 2 weeks?
*
Yes
No
Have you travelled outside Canada in the last 14 days?
*
Yes
No
Human Validation
Check The Box
*
Human Validation Failed, Please Try Again