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COP Return to Skating Health Screening
If an individual answers YES to any of the questions, they must not be allowed to participate in the sport or activity.
Children and youth will need a parent to assist them to complete this screening tool.
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* Indicates required question
What arena are you skating right now
*
COP
Other:
FULL NAME:
*
Your answer
SCREENING CHECKLIST
If an individual answers YES to any of the questions, they must not be allowed to participate in the sport or activity.
Children and youth will need a parent to assist them to complete this screening tool.
1. Does the person attending the activity, have any of the below symptoms:
Fever
*
YES
NO
Cough
*
YES
NO
Shortness of Breath / Difficulty Breathing
*
YES
NO
Sore throat
*
YES
NO
Chills
*
YES
NO
Painful swallowing
*
YES
NO
Runny Nose / Nasal Congestion
*
YES
NO
Muscle/joint aches (unrelated to training)
*
Yes
No
Feeling unwell / Fatigued
*
YES
NO
Nausea / Vomiting / Diarrhea
*
YES
NO
Unexplained loss of appetite
*
YES
NO
Loss of sense of taste or smell
*
YES
NO
Headache
*
YES
NO
Conjunctivitis (Pink Eye Symptoms)
*
YES
NO
Has the person attending the activity / facility traveled outside of Canada in the last 14 days?
*
YES
NO
Have you/your child had close, unprotected* contact (face to face contact within 2 metres/ 6feet) with someone who has travelled outside of Canada in the last 14 days and who is ill**? ** “ill” means someone with COVID-19 symptoms on the list above
*
YES
NO
Have you/your child attending the program or activity had close unprotected* contact (face toface contact within 2 metres/ 6 feet) in the last 14 days with someone who is ill**? “ill” means someone with COVID-19 symptoms on the list above
*
YES
NO
Have you/your child or anyone in your household been in close, unprotected* contact in the last14 days with someone who is being investigated or confirmed to be a case of COVID-19? * “unprotected” means close contact without appropriate personal protective equipment
*
Yes
No
If you have answered “YES” to any of the above questions do not participate. Proceed home and use the AHS OnlineAssessment Tool to determine if testing is recommended.
Street Address
*
Your answer
Postal code
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
Member Type
*
Skater
Parent
Coach/Volunteer/Staff
Time in
*
Time
:
AM
PM
Time out (5 minutes after your session ends) If you skate at two arenas at different times you must fill out two forms.
*
Time
:
AM
PM
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