Hockey Buds Staff COVID-19 Daily Assessment Tool

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Hockey Buds Coaching Staff for Fall 2021 Program Sessions.

Complete and submit the following Daily Assessment Questionnaire prior to entering the facility.

The questions are relevant to the staff, and all members of the family "bubble'. You should refrain from entering the facility if you or any member of your family "bubble" are experiencing potential COVID-19 symptoms.

This information is being collected with your consent and in accordance with PIPEDA for the purpose of compliance with the directives of the Chief Medical Officer of Health of Newfoundland and Labrador in response to the COVID-19 Public Health Emergency.

By completing this form you consent to the collection, use and disclosure of this information as directed by the Chief Medical Officer of Health or as required by law. This information will be stored securely by GameOn Sports for 14 days from the date the form was completed, after which time it will be deleted.

Upon request, this data will also be made available to the NLBHA and the Northpoint Sports Facility,

Email *

Staff Member's Name (First and Last): *

Includes all staff. [Coaches, Assistant Coaches and Organizers]

Staff Member's Parent/Guardian:

Must be completed by Parent/Guardian if Staff member is under the Age of 18.

Staff Member's Parent/Guardian Phone:

Must be completed by Parent/Guardian if Staff member is under the Age of 18.

Select Session Time (s) *

10:00 AM

11:00 AM

12:00 PM

Required

Do you have a fever and/or cough (new or worsening)? *

Yes

Do you have 2 or more of the following symptoms (new or worsening)? *

Must be completed by Parent/Guardian if Staff member is under the Age of 18.

Sore throat or difficulty swallowing

Headache

Unusual fatigue or lack of energy

New onset of muscle aches

Unexplained loss of appetite

Vomiting or Diarrhea

Loss of sense of smell or taste

Runny, stuffy or congested nose

Small red or purple spots on your hands and/or feet

NONE OF THE ABOVE

Required

Have you been in close contact with a known or suspected case of COVID-19 (probably or confirmed) within the last 14 days? *

Must be completed by Parent/Guardian if Staff member is under the Age of 18.

Yes

Have you or anyone in your household traveled outside Newfoundland and Labrador within the last 14 days? *

Fully and partially vaccinated travellers have no testing or self-isolation requirements. Unvaccinated workers follow current testing and isolation protocols. source: https://www.gov.nl.ca/covid-19/alert-levels/together-again/step-2/

Yes

Yes, however I am fully/partially vaccinated

If you answered YES to any of the previous questions DO NOT PROCEED TO FACILITY. Remain at home and self-isolate. Visit gov.nl.ca/COVID-19 or call 811. If you responded NO to all questions, you may proceed to facility. *

I understand.

Liability Waiver - check each box to acknowledge that you have read and understand each statement. *

Must be completed by Parent/Guardian if Staff member is under the Age of 18. Please check each box to acknowledge that you have read and understand each statement. If you do not understand each statement, please contact us at gameonsportsnl@hotmail.com

I acknowledge the contagious nature of COVID-19 and agree to adhere to distancing guidelines recommended by public health officials

I acknowledge COVID-19 exposure/infection may result from the actions of myself, others and their families

I agree to follow all safety precautions outlined by GameOn Sports, and governing sport bodies

I acknowledge GameOn Sports cannot guarantee that I will not become infected with COVID-19

Required

Send me a copy of my responses.

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