OFH Prescreening Form 2021/22 (St. George Minor Hockey)

Print OFH Prescreening Form 2021/22

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 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.

I agree to the terms and conditions stated above^*

Participant Information

Please enter participant's info here.

Session Information

Date of Session^*

Time of Session^*

Parent/Guardian Info

Please enter the name of the parent/guardian who will be dropping and or joining the participant at their session.

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

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

2. 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.

Headache that's unusual or long lasting
YesNo
Digestive issues (nausea/vomiting,diarrhea,stomach pain)
YesNo
Do you have a fever? (Feeling hot to touch, a temperature of 37.8 C 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
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 appetitie^*
YesNo

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
1. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19 ?^*
YesNo
2. In the past 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? (This does not include essential workers who cross the Canada-US border regularly)^*
YesNo
3. Have you travelled outside of Canada in the last 14 days ? (This does not include essential workers who cross the Canada- US border regularly)^*
YesNo
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)