KMHA COVID-19 Daily Screening Self-Assessment for U13_A01
COMPLETION OF THIS FORM IS REQUIRED BY ALL PARTICIPANTS PRIOR TO EACH TEAM EVENT AT U13.

REMINDER - THIS FORM IS ONLY VALID IF COMPLETED WITHIN 12 HOURS OF SORT OUT START TIME

A new form must be completed prior to attending each team event.

The answers to all multiple choice questions must be "NO" and/or "I AGREE" in order to participate in the specified KMHA sort out session.

登入 Google 即可儲存進度。瞭解詳情
電子郵件 *
Participant's Name (First and Last): *
Participant's Role at the Sort out Session: *
Accompanying Parent/Guardian/Spectator Name (First and Last):  (if no one, enter "N/A" in the field.) *
Date of the KMHA Team Event: *
MM
/
DD
/
YYYY
Start time of KMHA Team Event: *
時間
:
Location of Team Event: *
Do you (participant, parent, guardian and/or spectator) have any COVID-19 symptoms, including fever and/or chills, cough, shortness of breath, sore throat, difficulty swallowing, runny nose or congestion, decrease of taste or smell, pinkeye, headache, digestive issues, muscle aches, extreme tiredness, or falling down often (for older people) *
Is anyone that you (participant, parent, guardian and/or spectator) live with currently experiencing COVID-19 symptoms, or is awaiting a test result after experiencing symptoms? *If you are fully vaccinated (2 weeks after completion of last required dose), select "NO". *
In the last 14 days have you (participant, parent, guardian and/or spectator) travelled outside of Canada? (if exempt from federal quarantine requirements, select "NO") *
Has a doctor, health care provider, or public health unit told you (participant, parent, guardian and/or spectator) that you should currently be isolating? *
In the last 10 days have you (participant, parent, guardian and/or spectator) tested positive for COVID-19? *If you have since tested negative on a lab based PCR test, select "NO" *
In the last 14 days, have you (participant, parent, guardian and/or spectator) received a COVID alert exposure notification on your cell phone? *If you are fully vaccinated (2 weeks after completion of last required dose), or you have tested negative, select "NO" *
By agreeing, I acknowledge that if at any time after submission of my form and prior to start of my actual KMHA team event that if my health situation with respect to COVID has changed I will refrain from attending the event and/or ice session *
By agreeing, I acknowledge that all information above is accurate and I have agreed to follow the policies and procedures put in place by the KMHA upon attending the identified KMHA team event *
If you answered YES to any of the screening questions above. go home & self-isolate right away. Visit OttawaPublicHealth.ca/Coronavirus for more information as you may be eligible for a COVID-19 test.
If feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.
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。
提交
清除表單
請勿利用 Google 表單送出密碼。
reCAPTCHA
隱私權條款
Google 並未認可或建立這項內容。 檢舉濫用情形 - 服務條款 - 隱私權政策
Google 表單