Health Screening Questionnaire (Brampton Hockey Inc.)

Health Screening Questionnaire

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

Information

Participant Name^*

Required

Participant Type^*

Required

Location of On-Ice Session^*

Required

Date of On-Ice Session^*

Required

Time of On-Ice Session^*

Required

Terms and Conditions: Are you currently experiencing any of these issues? Call 911 if you are. You cannot participate in on-ice or off-ice activities.

1. Severe difficulty breathing (struggling for each breath, can only speak in single words)

2. Severe chest pain (constant tightness or crushing sensation)

3. Feeling confused or unsure of where you are

4. Losing consciousness

I agree to the terms and conditions stated above^*

Terms and Conditions:

If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating.

• Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)

• Having a condition that compromises (weakens) your immune system (for example, lupus, rheumatoid arthritis, immunodeficiency disorder)

• Having a chronic (long-lasting) health condition (for example, diabetes, emphysema, asthma, heart condition, COPD)

• Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

I agree to the terms and conditions stated above^*

Questions

The answer to all questions must be “No” in order to participate in any and all activity.

Are you currently experiencing any of these symptoms? Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher)^*

Required

Chills^*

Required

Cough that’s new or worsening (continuous, more than usual)^*

Required

Barking cough, making a whistling noise when breathing (croup) ^*

Required

Shortness of breath (out of breath, unable to breathe deeply) ^*

Required

Sore throat^*

Required

Difficulty swallowing ^*

Required

Runny nose, sneezing or nasal congestion (not related to seasonal allergies or other known causes or conditions)^*

Required

Lost sense of taste or smell ^*

Required

Pink eye (conjunctivitis) ^*

Required

Headache that’s unusual or long lasting ^*

Required

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

Required

Muscle aches^*

Required

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

Required

Falling down often ^*

Required

For young children and infants: sluggishness or lack of appetite ^*

Required

Close Contact - The answer to all questions must be “No” in order to participate in any and all activity (on-ice or off-ice)

For the remaining questions, close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes. Living in the same home

If an individual has answered “Yes” to any of these questions, they are not permitted to participate in any on-ice or off-ice activities.

In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?^*

Required

In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks? (This does not include essential workers who cross the Canada-US border regularly.)^*

Required

. Have you travelled outside of Canada in the last 14 days? (This does not include essential workers who cross the Canada-US border regularly.)^*

Required

Terms and Conditions: If an individual has answered “Yes” to any of these questions, they are not permitted to participate in any on-ice or off-ice activities.

I agree to the terms and conditions stated above^*

Health Screening Questionnaire (Brampton Hockey Inc.)

OMHA Digital Network

Information

Questions

Close Contact - The answer to all questions must be “No” in order to participate in any and all activity (on-ice or off-ice)

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