GCSSC COVID-19 Screening 2021-22 Season

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Each individual must complete this questionnaire each time in order to participate in any Gloucester Concordes Speed Skating Club activities. Activities include skating practices, dryland, skate fitting and registration.

Please submit this questionnaire before your arrival at the arena. Our club Safety Officer will perform an active screening upon arrival at the club activity.

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電子郵件 *

Skater Name *

Phone Number *

Activity Date *

YYYY

Are you currently experiencing any of these symptoms? *

1 分

Fever and/or chills - Temperature of 38 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup) not related to other known causes

Shortness of breath, Out of breath, unable to breathe deeply

Sore throat not related to seasonal allergies, acid reflux, or other known causes

Difficulty swallowing Painful swallowing not related to other known causes

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

Decrease or loss of taste or smell not related to other known causes

Pink eye - Conjunctivitis not related to other known causes

Headache - Unusual, long-lasting (not related to getting a COVID-19 vaccine)

Digestive issues - Nausea/vomiting, diarrhea, stomach pain not related to other known causes

Muscle aches/joint pain - Unusual, long-lasting not related to other known causes

Extreme tiredness - Unusual, fatigue, lack of energy not related to other known causes

None of the Above

必填

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

1 分

Yes

In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)? *

1 分

Yes

In the last 14 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 (for example, you are fully vaccinated or for another reason), select “No.” *

1 分

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

1 分

Yes

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit? *

1 分

Yes

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? *

1 分

Yes

系統會透過電子郵件將你的作答內容複本傳送到你所提供的地址。