COVID Health Screening Questionnaire

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This questionnaire must be completed by each individual prior to participating in any Club or OVA activity. The answer to all questions in Section 1 must be “No” to participate.

Which program are you participating in? *

Athlete Name (Last, First) *

1. In the last 14 days, has the athlete/child or anyone they live with travelled outside of Canada? If exempt from quarantine requirements (double vaccinated), select “No.”

Yes

Clear selection

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

Yes

Clear selection

3. In the last 14 days, has the athlete/child been identified as a “close contact” of someone who currently has COVID-19?

Yes

Clear selection

4. In the last 14 days, has the athlete/child received a COVID Alert exposure notification on their cell phone?

Yes

Clear selection

5. Is the athlete/child currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions they already have. *

Fever - Temperature of 37.8 degrees Celsius - 100 degrees Fahrenheit or higher

Chills

Cough that's new or worsening - Continuous, more than usual, not related to other known causes or conditions (for example, COPD)

Barking cough, making a whistling noise when breathing - Croup, not related to other known causes or conditions

Shortness of breath - Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma)

Decrease or loss of taste or smell - Not related to other known causes or conditions (for example, allergies, neurological disorders)

Sore throat - Not related to other known causes or conditions (for example, seasonal allergies, acid reflux)

Difficulty swallowing - Painful swallowing, not related to other known causes or conditions

Runny nose - Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather)

Stuffy or congested nose - Not related to other known causes or conditions (for example, seasonal allergies)

Headache that’s unusual or long lasting - Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines)

Digestive issues like nausea/vomiting, diarrhea, stomach pain - Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps)

Extreme tiredness that is unusual - Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction)

Muscle aches that are unusual or long lasting - Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia)

Pink eye - Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes)

Sluggishness or lack of appetite - For young children and infants

None of the Above

Required

6. Is someone that the athlete/child lives with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Yes

Clear selection

Have you taken a test and are awaiting COVID-19 test results? If yes, please refrain from coming to practice. *

Yes

Have you travelled outside of Canada in the last 14 days? Note: This does not apply if you are exempt from the 14 day quarantine *

Yes

Exempt from Quarantine

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