2020 Health Screening - U11 Group B (Dorchester Minor Hockey Association)

Print 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^*
Event Type^*

Event Date^*

Open the calendar popup.

MM/DD/YYYY format to type directly

Event Time^*

Open the time view popup.

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)^*
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. (Answer "No" for not applicable.)^*
YesNo

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?^*
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 breationg - OR - Returned from outside of Canada in the last 2 weeks?^*
YesNo
Have you travelled outside Canada in the last 14 days?^*
YesNo