Team Ontario Astros 2021 COVID Assessment Form
If you answer "yes" to any of the following Questions, you should not enter the facility. You should go home or stay home to self-isolate immediately and contact your healthcare provider, or Telehealth Canada
(1-866-797-0000) to find out if you need a COVID-19 test
Sign in to Google to save your progress. Learn more
Name (First and Last)
Do you have a fever and/or chills? Temperature of 37.8 degrees Celsius or higher?
Clear selection
Cough or barking cough - continuous, more than usual, making a whistling noise when breathing not related to other cause or conditions such as asthma?
Clear selection
Shortness of breath/ unable to breathe deeply, not related to any known causes or conditions
Clear selection
Decrease or loss of smell or taste, not related to other cause of conditions
Clear selection
Sore throat or difficulty swallowing- painful swallowing, not related to other cause or conditions
Clear selection
Runny, stuffed or congested nose not related to any other cause or condition.
Clear selection
Headache that's unusual or long lasting, not related to other cause or conditions
Clear selection
Nausea, vomiting or diarrhea, not related to other known causes or conditions.
Clear selection
Extreme tiredness that is unusual or muscle aches- fatigue, lack of energy not related to other causes or conditions
Clear selection
Have you ore someone from your household travelled outside of Canada in the last 14 days? If you are an essential worker who crosses the Canada-US border regularly for work, please select "No"
Clear selection
In the Last 14 days, has a public health unit identified you or someone in your house as a close contact of someone who currently has COVID-19
Clear selection
Has a doctor, healthcare provider, or public health unit told you that you or someone from your household should currently be isolating?
Clear selection
In the Last 14 days, have you or someone from your household received COVID Alert Exposure notification on your cell? If you already went for your test and got a negative result, select "No"
Clear selection
I acknowledge the contagious nature of COVID-19 and that the public health authorities still recommend practicing social distancing. I further acknowledge that The Dugout Baseball and Softball Academy has put in place preventative measures to reduce the spread of COVID-19. I further acknowledge that The Dugout Baseball and Softball Academy can not guarentee that I will not become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by COVID-19 may result from the action, omissions, or negligence of myself and others, including but not limited to, facility staff, and other clients and their families. I voluntarily seek services provided by The Dugout Baseball and Softball Academy and acknowledge that I am increasing my risk of exposure to COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending all in person practice/training.
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms