Daily Health Screening Checklist

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Daily Health Screening Checklist - Masters PM

This tool is meant to be used to assist with assessing attendees who may be symptomatic, or who may have been exposed to someone who is ill or has confirmed COVID-19.

Please complete this checklist prior to EVERY practice. If an individual answers yes to any of the questions, they CANNOT participate in the sport for everyone's safety. Children and youth will need a parent to assist them to complete this screening tool.

* Face-to-face contact within 2 metres. A health care worker in an occupational setting wearing the recommended personal protective equipment is not considered to be a close contact.

** ‘Ill/symptomatic’ means someone with COVID-19 symptoms on the list above.

If you have answered “yes” to any of the above questions do not participate. Go home and use the AHS
Online Assessment Tool to determine if testing is recommended.

Email Address *

Name of Athlete, Coach or Volunteer *

Does the attendee have any new onset (or worsening) of any of the following symptoms? *

Yes

Fever

Cough

Shortness of breath/difficulty breathing

sore throat

Chills

Painful Swallowing

Runny Nose / Nasal Congestion

Feeling Unwell / Fatigued

Nausea / Vomiting / Diarrhea

Unexplained loss of appetite

Loss of sense of taste or smell

Muscle / joint aches

Headache

Conjunctivitis (pink eye)

Has the attendee traveled outside of Canada in the last 14 days? * *

Yes

Has the attendee had close contact* with a confirmed case of COVID-19 in the last 14 days? *

Yes

Has the attendee had close contact with a symptomatic ** close contact of a confirmed case of COVID-19 in the last 14 days? *

Yes

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