COVID ASSESSMENT QUESTIONAIRE - under 18 Atom U12- Coach Jason Caparilli- Red team RMS Events Peterborough Minor Ball Hockey

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COVID ASSESSMENT QUESTIONAIRE - under 18 Atom U12- Coach Jason Caparilli- Red team RMS Events Peterborough Minor Ball Hockey - OBHA

This assessment form must be completed within 3hrs prior to the participant attending their scheduled Ball Hockey Floor time each day you are going to be on the floor with the Peterborough Minor Ball Hockey League OBHA. Please read through the questionnaire and answer all of the questions. Please answer all questions accurately. Players who arrive at activities and appear to be symptomatic will not be allowed to participate. If your player is not feeling well, or showing any signs of any illness please keep them home. If you have any symptoms or answer yes you must stay home for a minimum of 24 hours after the last symptom subsides. You are given 2 options on the form: *PASS = answered "NO" to all questions and players are permitted to participate *FAIL- answered "YES" to any of the questions and players are NOT permitted to participate. Please notify Coach if your child is not attending and the reasons for missing, this is for tracking purposes.

If this form is not completed within the time frame the participant will not be permitted on the floor. Copies of this form will be going to your coach to ensure everyone has completed it and a copy to our league for our records. You will receive a copy as well for your records.

I am taking this screening as a: *

Participant

Parent/guardian on behalf of participant

Participant Name *

Parent/Guardian Name *

Parent/Guardian Contact Phone Number *

Parent/Guardian email *

In the last 14 days, have you/they or anyone they live with travelled outside of Canada?If exempt from quarantine requirements (for example, an essential worker who crosses the Canada-US border regularly for work), select “No.” *

yes

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

yes

In the last 14 days, have you/they been identified as a “close contact” of someone who currently has COVID-19? *

yes

In the last 14 days, have you/they received a COVID Alert exposure notification on their cell phone?If you/ they already went for a test and got a negative result, select “No.” *

yes

Are you/they currently experiencing any of these symptoms?Choose any/all that are new, worsening, and not related to other known causes or conditions they already have. *

Fever and/or chills Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup)Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have)

Shortness of breathOut of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have)

Decrease or loss of taste or smellNot related to seasonal allergies, neurological disorders, or other known causes or conditions they already have

Sore throat or difficulty swallowingPainful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions they already have)

Runny or stuffy/congested noseNot related to seasonal allergies, being outside in cold weather, or other known causes or conditions they already have

HeadacheUnusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions they already have)

Nausea, vomiting, and/or diarrheaNot related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have

Extreme tiredness or muscle achesUnusual, fatigue, lack of energy, poor feeding in infants (not related to depression, insomnia, thyroid dysfunction, sudden injury, or other known causes or conditions they already have)

None of the above

Required

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

yes

Personal information is collected under the authority of the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020, Ontario Regulation 364/20. The information will be used to screen for COVID-19 risk factors prior to entering a County of Peterborough facility or participating in a hockey program. In the event of a confirmed COVID-19 diagnosis that coincides with your visit, by completing and submitting this form, you consent to the PMBHL(OBHA) Executive sharing your name and contact information with Peterborough Public Health, for purposes of contact tracing to reduce the spread of COVID-19. ********************************************************** I have answered no to all questions and I/they will be at Ball Hockey today *

yes

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