Health Screen - Refs/timekeepers (Peterborough Girls Hockey Association)

Print Health Screen - Refs/timekeepers
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
1. Are you experiencing any of these symptoms?
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 the following questions it is recommended that you self isolate and consider getting tested for COVID 19.
For the remaining questions, close physical contact means: Being less than 2 meters away in the same room, workspace, or area for over 15 minutes or living in the same home.
Please complete a separate form for each person for every activity.
  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