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 any of the following new or worsening symptoms or signs? (symptoms should not be chronic or related to other known causes or conditions)
  • Fever or chills; difficulty breathing or shortness of breath; cough, sore throat, trouble swallowing; runny nose/stuffy nose or nasal congestion; decrease or loss of smell or taste; nausea, vomiting, diarrhea, abdominal pain; and/or not feeling well, extreme tiredness, or sore muscles.
  • If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild headache, muscle ache/joint pain, mild fatigue that only began after vaccination, select "NO".  Note: if this applies to you, you must wear a properly fitted medical mask for the entire time at work.  You may take the mask off to eat or drink.  You must stay at least 2 metres away from others while the mask is off.  If your symptoms worsen past 48 hours or you develop other symptoms:  you shall leave the Town facility and self-isolate and get a COVID-19 test.

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

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* 5. In the last 10 days, have you tested positive on a rapid antigen test or a home based self-testing kit?
  • If you have since tested negative on a lab-based PCR test, select "NO".

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* 6. Have you had close contact with a confirmed or probable case of COVID-19 within the last 14 days?  
  • If you are fully vaccinated and have not been advised to self-isolate by public health, select "NO".

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* 7. In the last 14 days, have you received a COVID-19 alert exposure notification on your cell phone?
  • If you are fully vaccinated and/or have already gone for a test and got a negative result, select "NO".

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* 8. In the last 14 days, have you travelled outside Canada AND been advised to quarantine per the Federal Quarantine Requirements?

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* 9. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for results after experiencing symptoms?
  • If you are fully vaccinated, select "NO".  If the individual is experiencing mild symptoms following a COVID-19 vaccination in the last 48 hours, select "NO".

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

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