This questionnaire must be completed by each individual DAILY prior to participation in each on-ice or off-ice club/skating school activity. This questionnaire must be completed separately for each individual entering the facility on the date.
The answer to all questions must be “No” in order to participate in each on-ice activity.
If you have answered “Yes” to any of these questions, you are not permitted to participate in any on-ice or off-ice club/skating school activities.
Please note: This Health Screening questionnaire has been developed based on the current Ontario Ministry of Health Self-Assessment Tool.

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* 1. Date Skating:

Date

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* 2. Participant First and Last Name

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* 3. Do you have the symptom: Fever and/or chills (Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher)

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* 4. Do you have the symptom: Cough or barking cough (croup) (Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

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* 5. Do you have the symptom: Shortness of breath (Out of breath, unable to breathe deeply, not related to asthma or other known causes or conditions you already have)

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* 6. Do you have the symptom: Sore throat / Difficulty Swallowing / Painful Swallowing (Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)

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* 7. Do you have the symptom: Decrease or loss of smell or taste (Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have)

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* 8. Do you have the symptom: Pink eye / Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)

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* 9. Do you have the symptom: Runny or stuffy/congested nose (Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have)

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* 10. Do you have the symptom: Headache (Unusual, long-lasting, not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)

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* 11. Do you have the symptom: Digestive issues like nausea/vomiting, diarrhea, stomach pain (Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have)

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* 12. Do you have the symptom: Muscle aches (Unusual, long-lasting, not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have)

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* 13. Do you have the symptom: Extreme tiredness (Unusual, fatigue, lack of energy, not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

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* 14. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?

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

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* 16. In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."

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* 17. In the last 14 days, have you or anyone you live with travelled outside of Canada? If you or anyone you live with are exempted from federal quarantine as per Group Exemptions, Quarantine Requirements under the Quarantine Act, select “No”.

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

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* 19. NON-MEMBERS ONLY: Please provide contact information

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