GVA/Viper Volleyball Academy COVID-19 Health Screening Questionnaire

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To be completed every day before going to a practice session or OVA Activity by all Athletes and Coaches.

Full Name of Participant: *

Date: *

YYYY

1. Does your child/Athlete live and/or go to school/childcare in Toronto or Peel Region: *

Yes

2. Is the child/athlete currently experiencing any of these symptoms:

Fever and/or chills *

Temp of 37.8˚C/100˚F or higher

Yes

Cough or barking cough *

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

Yes

Decrease or loss of smell or taste *

Not related to seasonal allergies, neurological disorders, or other known causes or condition

Yes

Sore throat or difficulty swallowing *

Painful swallowing (not related to seasonal allergies, acid reflux, or other know causes or conditions

Yes

Runny or stuffy/congested nose *

Not related to seasonal allergies, being outside in cold weather, or other know causes or conditions

Yes

Headache *

Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes)

Yes

Nausea, vomiting, and/or diarrhea *

Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other know causes or condition)

Yes

Extreme tiredness that is unusual or muscle aches *

Unusual fatigue, lack of energy, poor feeding in infants (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions they already have)

Yes

Falling down often or slugishness *

Yes

Pink eye *

Yes

3. In the last 14 days, has the child/athlete travelled outside of Canada? *

Yes (not fully vaccinated and/or no proof of negative test)

Yes - but have proof of double vaccination and proof of negative COVID test upon return (please present proof to your coach in this instance to pass the screener)

4. In the last 14 days, have you been in close contact with someone who returned from outside of Canada and is not an essential worker with exemption from quarantine? *

Yes

5. In the last 14 days, has the child/athlete been identified as a “Close Contact” to someone who currently has COVID -19? *

Yes

6. In the last 14 days, has the child/athlete received a COVID Alert exposure notification on their cell phone? (If they already went for test and received negative result, select “NO”) *

Yes

7. Has a doctor, Health Care Provide or Public Health Unit told you that the child/athlete should currently be isolated (Staying at home)? *

Yes

If your answer has been YES to any of the above questions please stay home and notify your coach.

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