Covid-19 Screening (Peterborough Hockey Association)

Print Covid-19 Screening
Please read through the questionnaire and answer all of the questions. Please answer all questions accurately. Players who arrive at activities and appear to be symptomatic will not be allowed to participate. If your player is not feeling well, or showing any signs of any illness please keep them home. If you have any symptoms or answer yes you must stay home for a minimum of 24 hours after the last symptom subsides. You are given 2 options on the form: *PASS - answered "NO" to all questions and players are permitted to participate *FAIL- answered "YES" to any of the questions and players are NOT permitted to participate. Please notify Coach if your child is not attending and the reasons for missing, this is for tracking purposes. You will automatically get an email and will show this to the person filling out the tracking sheet starting Saturday Sept 12th 2020.
Player Identification
  1. Example: [email protected] Your submission will be sent to this address.
  2. Example: ###-###-####
  1.  This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity. This questionnaire may be completed verbally.

    Are you currently experiencing any of these issues? Call 911 if you are.

    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 


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

    1. 70 years old or older 

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

    3. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition) 

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



Self Assesment
Assessment Continued
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
Human Validation
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Printed from on Thursday, November 26, 2020 at 12:41 PM