U11 COVID-19 Health Screening Questionnaire (Thamesford Area Minor Hockey Association )

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U11 COVID-19 Health Screening Questionnaire
Each player and accompanying parent/guardian must fill out the questionnaire prior to entering the arena each practice or game. Thanks
ONTARIO HOCKEY FEDERATION - Health Screening Questionnaire

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) The answer to all questions must be “No” in order to participate in any and all activity.

Participant

Contact, Team and Event information for the Participant or Spectator screened in this form. EACH PERSON NEEDS THEIR OWN FORM. EXAMPLE, ONE PLAYER AND ONE PARENT WATCHING MEANS TWO FORMS ARE NEEDED.

The answer to all screening questions must be "No" in order to participate in any and all activity.  If one or more questions are answered "Yes", please advise your team's representative immediately and DO NOT ENTER THE ARENA.

Participant Screening

Are you currently experiencing any of these symptoms?

Contacts & Recent Travel

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.