Basketball Active Screening Questionnaire

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Active Screening is a health review of your child. Completing Active Screening is a mandate of the Ministry of Health and Ottawa Public Health for participation in Summer Sports programs. Submitting this Questionnaire makes it easy for you to comply.

It helps everyone remain safe and healthy!

Information collected will only be used by the Manor Park Community Council (MPCC) for the administration and management of 'Physically Active and Physically Distanced Programs' and will only be shared if legally required.

Your Childs Name *

Does your child have one or more of the following symptoms? Check all that apply. *

Fever (37.8 degrees C or higher)

Chills

Cough that's new or worsening (continuous, more than usual)

Barking cough, making a whistling noise when breathing (croup)

Sore throat

Difficulty swallowing

Runny, stuffy, or congested nose (not associated with allergies or other known condition)

Lost sense of taste or smell

Pink eye (conjunctivitis)

Headache that's unusual or long-lasting

Digestive issues (nausea / vomiting, diarrhea, stomach pain)

Muscle aches

Extreme tiredness that is unusual (fatigue, lack of energy)

Falling down often

Sluggishness or lack of appetite

None of the above

Required

Does your child have an inflammatory condition? Check all that apply. NOTE: A doctor's note is required to return to the program. *

Rashes

Prolonged fever

Red eyes

Abnormal swelling in the hands or feet that requires medical attention

None of the above

Required

As parent / guardian of the child, I attest that: my child has NOT travelled outside of Canada (including the United States) in the last 14 days; my child has NOT had close contact with a confirmed or probable Covid-19 case, and my child has NOT had close contact with a person with acute respiratory illness who has been outside of Canada (including the United States) in the last 14 days. *

Yes, I attest.

No, I do not attest.

Notice of Risk from Ottawa Public Health:

When children from multiple families attend any sports program, there is an increased risk of the Covid-19 virus coming into the program. Children who are infected with the Covid-19 virus are more likely than adults to have very mild infections or to have no symptoms at all, but these children can still transmit the infection to other children and to adults. This means that children can bring home an infection acquired at a program and put other persons at risk. Even if that program has a screening process to help detect infections when there are symptoms; this screening process will not detect infected children or adults who do not have symptoms at the time of screening.

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