OM Hockey Daily COVID-19 Screening Form

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Please complete the below questionnaire prior to entering the arena facility and within 12 hours of your game time.

REMINDER – THIS FORM IS ONLY VALID IF COMPLETED WITIN 12 HRS OF YOUR GAME TIME.

Email *

Participant Name (First & Last) *

Accompanying Spectator(s) Name (First & Last)

Date of your game *

YYYY

City Arena of your game *

Bell Centennial

Nepean Sportsplex

Walter Baker

Kanata Recreation Complex

Minto Recreation Complex

Your Team *

Andrew's Dunlop's

Cliff's Chiefs

Dave's Killers

Les Hanson

Louis McCracken's

Spare Player

Official

A. Do you or anyone you live with have ONE OR MORE of these new or worsening symptoms (not related to other known causes or conditions)? including fever and/or chills, cough, difficulty breathing, decrease/loss of smell and taste *

Yes

B. Do you or anyone you live with have TWO OR MORE of these new or worsening symptoms(not related to other known causes or conditions)? Sore throat, Headache*, Very Tired*, Runny / stuffy nose, Muscle aches / Joint pain*, Nausea / vomiting / diarrhea *If mild tiredness, sore muscles/joints or headache occur within 48 hours after getting a COVID-19 vaccine or flu shot, answer “No” and continue to follow all public health measures. If symptoms last longer than 48 hours or worsen, answer “Yes.” If the person you live with has not tested positive for COVID-19 and only has one of these symptoms: sore throat or difficulty swallowing, runny or stuffy/congested nose, headache, extreme tiredness, muscle aches or joint pain, nausea, vomiting and/or diarrhea, answer “No.” If you have only one symptom from part B, stay home until the symptom improves for at least 24 hours or 48 hours if nausea / vomiting /diarrhea. *

Yes

If you are sick or have any symptoms of illness, including those not listed above, stay home and contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.

In the last 14 days 1. Have you travelled outside of Canada AND are currently required to be in quarantine per the federal quarantine requirements? *

Yes

In the last 5 days 2. Have you or anyone in the household tested positive for COVID-19 on a rapid antigen test or PCR test? *

Yes

In the last 5 days 3. Have you received a COVID Alert exposure notification on your cell phone? If you are fully vaccinated answer "No." *

Yes

In the last 5 days 4. Have you been identified as a “close contact (high risk contact)” of someone who has tested positive for COVID-19?• If you are fully vaccinated AND DO NOT live with the person who tested positive or has symptoms, answer “No.”• If public health has advised you that you do not need to self-isolate, answer "No." *

Yes

By agreeing, I acknowledge that if at any time after submission of my form and my actual ice session that if my health situation with respect to COVID has changed I will refrain from attending the session. *

I AGREE

I DISAGREE

By agreeing, I acknowledge that all information provided above is accurate and I have agreed to follow the policies and procedures put in place by Ottawa Public Health upon entering the building. *

I AGREE

I DISAGREE

If you answered YES to any of these questions, please return home and self-isolate. Visit OttawaPublicHealth.ca/COVID19instructions for more information.

A copy of your responses will be emailed to the address you provided.

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