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CPYHA COVID Questionnaire
You are asked to complete this due to notification of possible exposure or a positive test result.
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* Indicates required question
Email
*
Your email
Your Name
*
Your answer
Name of Skater (if multiple skaters - please complete one questionnaire per child):
*
Your answer
Team
*
Choose
Bantam AA
Bantam B1
BAntam B2
Peewee AA
Peewee B1
Peewee B2
Peewee C
Squirt A
Squirt B1
Squirt B2
15U B
MITE
Choose what best applies:
Someone in our home has symptoms
Someone in our home has tested positive for COVID
Someone in our home was/may have been exposed to COVID
Other:
Who has symptoms and/or has tested? (Choose all that apply).
*
Parent(s)
Sibiling
Player
Coach
Other:
Required
If there are symptoms, but no test results, what are the symptoms? (Choose all that apply)
Fever
Chills
Headache
Body aches
Dry cough
Stuffy nose
Loss of smell
Other:
If possible exposure, when was the last time you/player/coach were last with the person with COVID? Or if symptoms, when did symptoms first begin?
Your answer
If parent or guardian is positive, has the player shown any symptoms? If so, what was the date symptoms first began?
Your answer
If the positive/symptomatic person is NOT the player, what is the date of last close contact with the player?
Your answer
What the the last time your player was with his/her team?
*
Your answer
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