COVID Screening Questionnaire
This questionnaire must be completed by each player, spectator and team staff member prior to attending a Woolwich Wild activity.

A member of the team staff will ask you to confirm that you have completed the questionnaire and answered no to all questions before you will be permitted to participate in the activity.  

Are you currently experiencing any of these issues? Call 911 if you are:
1. Experiencing severe difficulty breathing (struggling for each breath, can only speak in single words)
2. Experiencing 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. 70 years old or older
2. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)
3. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition)
4. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)


The answer to all questions must be “No” in order to participate in each on-ice activity.

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 or attend as a spectator.  Please call your trainer immediately and let them know that you have responded positively to questions in the Health Screening Questionnaire.  

Sign in to Google to save your progress. Learn more
Your first name: *
Your last name: *
Your phone number: *
Your email address: *
Purpose of your visit *
Age group of players: *
What day of the week is the ice time? *
What time is the ice time? *
Please review the following questions:
1. Are you currently experiencing one or more of the symptoms below that are new or worsening?  Symptoms should not be chronic or related to other known causes or conditions.
• Fever and/or chills
• Cough or barking cough (croup)
• Shortness of breath
• Decrease or loss of smell or taste
• For children < 18 years, nausea, vomiting and/or diarrhea
• For adults ≥ 18 years, unusual tiredness, lack of energy, fatigue, lethargy, malaise and/or myalgias

2. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
• This can be because of an outbreak or contact tracing.

4. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?  
• If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized† or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”

5. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
• If you have already gone for a test and got a negative result, select “No”.
• If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No".

6. In the last 10 days, have you tested positive on a rapid antigen test or a home based self-testing kit?
• If you have since tested negative on a lab-based PCR test, select “No”.

7. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
• If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No".

8. In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self isolate?
• If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No".

9. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
• If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No”.
• If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No”.

Is your answer 'Yes" to any of the above questions? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Woolwich Girls Minor Hockey Association. Report Abuse
Google Forms