HEALTH SCREENING QUESTIONAIRE (Peterborough Girls Hockey Association)

Print HEALTH SCREENING QUESTIONAIRE
This questionnaire must be completed by each individual prior to participation in each on-ice or off-ice activity. Version 8 – August 27, 2021 This screening tool provides advice, recommendations and instructions issued by the Office of the Chief Medical Officer of Health in accordance with O. Reg. 364/20: Rules for Areas at Step 3 made under the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020 (ROA).
1. Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.
Pleasae review list below for symptoms
  1. Please review the list below
  1. Fever and/or chills

    Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

    Cough or barking cough (croup)

    Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have

    Shortness of breath

    Not related to asthma or other known causes or conditions you already have

    Decrease or loss of smell or taste

    Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

    (For adults > 18 years or older)

     

     

     

    Fatigue. lethargy, malaise and/or myalgias

    Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

     

    If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”

    (For children < 18 years) Nausea, vomiting and/or diarrhea

    Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have


Please answer the following
  1. This can be because of anoutbreak or contact tracing
  2. If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”
  3. If you have already gone for a test and got a negative result, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."
  4. If you have since tested negative on a lab-based PCR test, select “No.”
  5. If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
  6. If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
  7. If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
PLAYER INFORMATION
Please complete a separate form for each player for every activity. A SEPARATE FORM needs to be completed for player and parent spectator.
  1. A separate form needs to be completed for EACH person entering the arena
  2. Example: ###-###-####
  3. Use email who will be dropping off player and providing confirmation of completed form
  1. This form MUST be completed THE DAY OF scheduled PGHA activity.  If symptoms change after you have completed this form please update.  

    You are required to show confirmation of completing this form to a PGHA representative prior to participating in the scheduled activity.
Human Validation