Daily Health Screening Questionnaire

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. Full Name:

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

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* 4. Do you have the following symptom: Cough (continuous, more than usual)

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* 5. Do you have the following symptom: Shortness of breath

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

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* 7. Do you have the following symptom: A Sore throat

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* 8. Do you have the following symptom: Difficulty swallowing

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* 9. Do you have the following symptom: Lost sense of taste or smell

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* 10. Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days?

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* 11. Have you had close contact in the past 14 days with anyone with a new cough, fever or difficulty breathing or a confirmed case of COVID-19?

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