2020-21 COVID-19 OHF/HHMH HEALTH SCREENING QUESTIONNAIRE (Halton Hills Minor Hockey)

Print 2020-21 COVID-19 OHF/HHMH HEALTH SCREENING QUESTIONNAIRE
  1. COVID-19 OHF/HHMH HEALTH SCREENING QUESTIONNAIRE

    For the purposes of COVID-19 Contact Tracing

    Terms and Conditions: 

    I acknowledge that only one (1) parent/guardian of each skater under 18 years of age is permitted in the facility as an observer. Parents/Guardians are to maintain physical distancing and follow the protocols as defined by the Town of Halton Hills and Halton Hills Minor Hockey.

    I acknowledge that I will submit this screener on the day of each scheduled session, prior to arriving at the arena.  I acknowledge that failure to do so may compromise my registration in the program.  


    I acknowledge that if I or any of my family have COVID-related symptoms, I will contact Halton Public Health Unit (PHU) for guidance and not attend any session until permitted by Halton Public Health Unit. 

    I acknowledge that if I or any of my family test positive for COVID-19, or awaiting results, I will contact Halton Public Health Unit (PHU) for guidance not attend any session until permitted as per Halton Public Health Unit.

    Participant/accompanying adult will complete the COVID-19 OHF/HHMH Health Screening Questionnaire (this form) no sooner than 12 hours ahead of any ice session and no later than 1 hour prior to any ice session they participate in.

    Trainer/Coach/Manager/HHMH staff will check-in participants and parents before entry to the facility before session.

    Trainer/Coach/Manager/HHMH staff to ask each participant: "Has anything changed since you completed the online screening form?"

    Trainer/Coach/Manager/HHMH staff to keep track on OHF Session Participation Tracking sheet for any parent who enters the facility with the participant.

    I acknowledge that if I, or any of my family are in self-quarantine for COVID-19 by request of Halton Public Health Unit (PHU) or other PHU or for personal reasons, I will not attend any session until permitted as per Halton Public Health Unit and/or after the 14 day quarantine period.


    I acknowledge that I/my player/participant will show or be instructed to show the team/group manager or delegate proof of this form before entering the dressing room area.
Team Info
  1. E.g. U12 Group 3, U15 Group 2
Session Info
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Participant Info
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Parent/Guardian Info
Please enter the name of the parent/guardian who will be dropping the participant at their session or attending the session with the participant.
  1. Your submission is sent to this address. Please keep the email for the duration of the season. Present it when required.
  1. 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
     
  2. 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)
  3. Terms and Conditions: The answer to all questions must be “No” in order to participate in any and all activity (on-ice or off-ice).

    Are you currently experiencing any of these symptoms?

    • Do you have a Fever? (Feeling hot to touch, temperature of 37.8C or higher)
    • Chills
    • Cough that is new or worsening (continuous, more than usual)
    • Barking cough, making a whistle noise when breathing (croup)
    • Shortness of breath (out of breath, unable to breathe deeply)
    • Sore Throat
    • Difficulty swallowing
    • Runny nose, sneezing, or nasal congestion (not related to seasonal allergies or other known causes or conditions)
    • Lost sense of smell or taste
    • Pink Eye (conjunctivitis)
    • Headache that's unusual or long lasting
    • Digestive issues (nausea/vomiting, diarrhea, stomach pain)
    • Muscle aches
    • Extreme tiredness that is unusual (fatigue, lack of energy)
    • Falling down often
    • For young children and infants: sluggishness or lack of appetite
  4. Terms and Conditions: 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 or living in the same home

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

    2.  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.)


    3. Have you travelled outside of Canada in the last 14 days? (This does not include essential workers who cross the Canada-US border regularly.)
  5. 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.
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    Printed from haltonhillsminorhockey.com on Friday, October 23, 2020 at 5:15 PM