2022 WTSC Covid-19 Protocols - Daily Health Screening Questionnaire

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This questionnaire must be completed by each individual prior to participation in WTSC programs.

This questionnaire must be completed separately for each individual participating in WTSC programs outside and/or entering the facility on the date. You cannot complete this questionnaire in advance and a new questionnaire must be submitted daily.

The answer to all questions must be “No” in order to participate in each on-ice activity. If you have answered “Yes” to any of these questions, you are not permitted to participate in any on-ice activities and please do not come to the rink.

Please note: This Health Screening questionnaire has been developed based on the current Ontario Ministry of Health Self-Assessment Tool.

Email *

Name(s) of people attending ( Skater, Parent/Guardian) *

Date of Session *

YYYY

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 Temperature of 37.8 degrees Celsius/100 degrees

Cough or barking cough (croup) Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Shortness of breath, unable to breathe deeply. Not related to asthma or other known causes or conditions you already have

Decrease or loss of smell or taste Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Muscle aches/joint pain. Unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)

Extreme tiredness. Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Sore throat. Painful or difficulty swallowing (not related to post-nasal drip, acid reflux, or other known causes or conditions you already have)

Runny or stuffy/congested nose. Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Headache. New, unusual, long-lasting (not related to getting a COVID-19 vaccine and/or flu shot in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Nausea, vomiting and/or diarrhea. Not related to irritable bowel syndrome, anxiety, menstrual cramps, medication side effects, or other known causes or conditions you already have

'No' to all of the symptoms listed

Required

1. In the last 5 days, has someone you live with: been sick with symptoms associated with COVID-19? and/or tested positive for Covid-19 ( on a rapid antigen or PCR test )?

2. In the last 5 days have you: been sick with symptoms associated with COVID-19? and/or tested positive for Covid-19 ( on a rapid antigen or PCR test )?

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 5 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 5 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."

No, None of the Above

Required

If you answered yes to any of the screening questions please do not come to the rink. Email office@wtsc.ca with your name, session date and time you will be missing. *For information on Travel Exemptions to the emergency order of the Government of Canada’s Quarantine Act, please go to: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/latesttravel-health-advice.html#a3

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