Game Officials Pre screening form (St. George Minor Hockey)

Print Game Officials Pre screening form
  1. I acknowledge that I will submit this screener no earlier than 12 Hours of each scheduled session, prior to arriving at the arena. 

    I acknowledge that I can submit this form up to 10 minutes to the participants scheduled ice time.

    I acknowledge that if I can't complete this questionairre in these time lines I will bring a completed form or retrieve paperwork at the screening table and complete the forms outside the arena. 
Participant Information
Please enter participant's info here.
  1. Example: ###-###-####
Session Information
  1. RadDatePicker
    Open the calendar popup.
  1. This questionnaire must be completed by each individual prior to participation in each on ice or off ice activity.

    Are you currently experiencing any of these issues?

    Call 911 if you are.

    1.  Severe difficulty breathing (struggling for each breath, can speak in single words

    Severe chest pain (constant tightness or crushing sensation)

    Feeling confused or unsure of where you are

    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. Getting treatment that compromises (weakens) your immune system (for example,     chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)

    Having a condition that compromises (weakens) your immune system (for example lupus, rheumatoid arthritis, immunodeficiency disorder)

    3. Having a chronic (long lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD)

    4.  Regularly going to a hospital to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

Are you currently experiencing any of these symptons
The answer to all questions must be “NO” in order to participate in any and all activity.
  1. For the remaining questions, close physical contact means

    ·         Being less than 2 metres in the same room, workplace, or area for over 15 minutes

    ·         Living in the same house

  2. 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

    Please note : This Health Screening questionnaire has been developed based on the Ontario Ministry of Health Self Assessment Tool ( September 14, 2020)
Human Validation
Printed from on Tuesday, March 2, 2021 at 5:25 AM