Active Screening Questionnaire for adults in recreation programs.

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Active Screening is a review of your health. Completing Active Screening BEFORE each participation in a recreational program is a mandate of the Ministry of Health and Ottawa Public Health. Submitting this Questionnaire electronically to the Manor Park Community Council (MPCC) makes it easy for you to comply.

It helps everyone remain safe and healthy!

Information collected will be used by the Manor Park Community Council for the administration and management of arts, sports, and fitness programs. Information will only be shared as legally required.

Your name *

Please note, close contact means:

Being within 2 metres (6 feet) of a person; the longer they were within 2 metres the higher the risk.

Living within the same household or providing care to a person (e.g., bathing, feeding, or dressing), without the use of Personal Protective Equipment (PPE) appropriate to the setting AND/OR where there were breaches or contamination of PPE (e.g., improper or inconsistent use of medical facemask and eye protection).

Physical contact (e.g., shaking hands, hugging, kissing, being sneezed or coughed on).

Interactions where people briefly come within 2 metres (6 feet) of each other, such as walking by someone in the hallway or on the street, are generally not considered close contacts.)

Have you been in close contact with someone who has tested positive for COVID-19 in the past 14 days? *

Yes

In the last 14 days have you been in close contact with someone who returned from outside of Canada in the last 2 weeks? *

Yes

Have you been in close contact with someone with new COVID-19 symptoms (like a cough, fever, runny nose or difficulty breathing) in the last 14 days? *

Yes

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

Yes

Do you have any of these symptoms? If so, please stay home, complete an online Covid-19 Self-Assessment and follow guidance on testing. *

Fever (37.8 degrees C or higher)

Chills

Cough that's new or worsening (continuous, more than usual)

Barking cough, making a whistling noise when breathing (croup)

Shortness of breath (unable to breathe deeply or feeling unable to catch one's breath)

Sore throat (not related to seasonal allergies or other known conditions)

Difficulty swallowing

Runny, stuffy, or congested nose (not associated with allergies or other known condition)

Lost sense of taste or smell

Pink eye (conjunctivitis)

Headache that's unusual or long-lasting

Diarrhea or stomach pain

Nausea or vomiting

Muscle aches

Extreme tiredness that is unusual (fatigue, lack of energy)

Falling down often

Sluggishness or lack of appetite

Unexplained rashes

None of the above

Required

Have any of your household contacts (family, roommates) or other contacts presented with Covid-19 symptoms in the last 14 days? *

Yes

If you have answered YES to any of the above questions or are symptomatic you should not attend or participate any in-person programs with the Manor Park Community Council.

Visit www.ottawapublichealth.ca for more information on being tested and self isolating. Thank you for your understanding.

Notice of Risk from Ottawa Public Health:

The risk of serious Covid-19 infection increases with age, which older persons should consider in terms of risk to themselves. This caution also applies to those persons of any age who have chronic medical conditions that may put them at an increased risk for serious illness with Covid-19 infection.

Even if there is a screening process to help detect infections when there are symptoms, this screening process will not detect infected children or adults who do not have symptoms at the time of screening.

I attest that the information provided is true. *

Yes, I attest.

No, I do not attest.

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