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.

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

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.

In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?^*
YESNO
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?^*
YESNO
Have you travelled outside of Canada in the last 14 days?^*
YESNO

CONTACT INFORMATION

Please complete a separate form for each person for every activity.

Name^*

A separate form needs to be completed for EACH person entering the arena
Role^*
Referee Timekeeper
Arena^*
Memorial Center
Evinrude
Kinsmen
Cavan Monaghan Community Centre
Norwood

Date & Time Start of Activity^*

Open the calendar popup.

Open the time view popup.

Contact Phone Number^*

Example: ###-###-####
Contact Email^*

Use email who will be dropping off player and providing confirmation of completed form

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.

I agree to the terms and conditions stated above^*

Human Validation