Active Screening Questionnaire

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Active Screening is a health review for all participants. Completing Active Screening is a mandate of the Ministry of Health and Ottawa Public Health for participation in Summer Sports programs. Submitting this Questionnaire makes it easy for you to comply.

It helps everyone remain safe and healthy!

Information collected will only be used by the Manor Park Community Council (MPCC) for the administration and management of 'Stay Strong & Stable' and will only be shared if legally required.

Your Name *

Do you have one or more of the following symptoms? Check all that apply. *

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)

Sore throat

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

Digestive issues (nausea / vomiting, diarrhea, stomach pain)

Muscle aches

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

Falling down often

Sluggishness or lack of appetite

None of the above

Required

Do you have an inflammatory condition? Check all that apply. NOTE: A doctor's note is required to return to the program. *

Rashes

Prolonged fever

Red eyes

Abnormal swelling in the hands or feet that requires medical attention

None of the above

Required

I attest that: I have NOT travelled outside of Canada (including the United States) in the last 14 days; I have NOT had close contact with a confirmed or probable Covid-19 case, and I have NOT had close contact with a person with acute respiratory illness who has been outside of Canada (including the United States) in the last 14 days. *

Yes, I attest.

No, I do not attest.

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