Metcalfe Jets COVID-19 Daily Screening
Please complete the below questionnaire for everyone in your family (participant, player and team official) within your family prior to your visit to any City Arena.  Please note - this form is only valid if completed on the same day as your visit.
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Email *
Phone Number *
Individual #1 Full Name *
I am a: *
Individual #2 Full Name
I am a:
Clear selection
Individual #3 Full Name
I am a:
Clear selection
Individual #4 Full Name
I am a:
Clear selection
Date of Ice Session *
MM
/
DD
/
YYYY
Start Time of Ice Session *
Time
:
Arena Location *
Are you or anyone listed above as either a participant, spectator or team official currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have. *
Required
In the last 10 days, have you or anyone listed above as either a participant, spectator or team official been identified as a “close contact” of someone who currently has COVID-19?  If you are fully vaccinated and have not been advised to self-isolate by your doctor, health care provider, or public health unit, select "No". *
In the last 10 days, have you or anyone listed above as either a participant, spectator or team official received a COVID Alert exposure notification on your cell phone? *
In the last 10 days, have you or anyone listed above as either a participant, spectator or team official been in close physical contact with someone who either: a) is sick with a new cough, fever, difficulty breathing, or other symptoms associated with COVID-19? (not related to getting a COVID-19 vaccine in the last 48 hours) or b) returned from outside of Canada in the last 2 weeks? Close physical contact means any of the following while not wearing the appropriate personal protective equipment (PPE): being less than 2 metres away in the same room, workspace, or arealiving in the same homebeing in the same classroom *
In the last 14 days, have you or anyone listed above as either a participant, spectator or team officialtravelled outside of Canada? If exempt from federal quarantine requirements (for example, you are fully vaccinated and have met the specific conditions, or an essential worker who crosses the Canada-US border regularly for work), select “No.” *
By agreeing, I acknowledge that all information provided above is accurate for myself or anyone listed above as either a participant, spectator or team official and I have agreed to follow the policies and procedures put in place by the MDHA, the City of Ottawa and authorized Health Authorities upon entering either building. *
Required
If you answered YES for yourself or anyone listed above as either a participant, spectator or team official to any of the screening questions above, go home & self-isolate right away and inform the Risk and Safety officer within your association. Visit OttawaPublicHealth.ca/Coronavirus for more information as you may be eligible for a COVID-19 test.
A copy of your responses will be emailed to the address you provided.
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