Skate Ontario Health Screening Form

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This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice club/skating school
activity.

This includes participation in sessions on rented ice outside of a club/skating school setting.

The answer to all questions must be “No” in order to participate in each on-ice activity.

*Please note: This Health Screening questionnaire has been developed based on the current Ontario Ministry of
Health Self-Assessment Tool

Email *

Skater First and Last Name *

Contact Phone Number *

Which Organization are you skating for today? *

Whitby Figure Skating Club

Whitby Synchronized Skating Teams

What Date are you Skating (for current form use) *

YYYY

What Time are you Skating (for current form use) *

Time

Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher) *

Yes

Do you have a Cough (continuous, more than usual) *

Yes

Do you have Shortness of breath *

Yes

Do you have Runny nose, sneezing or nasal congestion (not related to other known causes such as seasonal allergies etc.) *

Yes

Do you have a Sore throat *

Yes

Do you have Difficulty swallowing *

Yes

Do you have Lost sense of taste or smell *

Yes

Have you travelled outside of Canada in the past 14 days or had close contact with anyone that has travelled outside of Canada in the past 14 days that does not have a Government of Canada Travel Exemption*? *

Yes

Have you had close contact in the past 14 days with anyone with active respiratory illness or an active confirmed or probable case of COVID-19? *

Yes

A copy of your responses will be emailed to the address you provided.

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