Self-Screening

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Self-Screening Assessment Questionaire



Collection of Personal Information

Personal information on this form is collected in accordance with the Municipal Freedom of Information and Protection of Privacy Act.  It is to be used for the purpose of administering health and safety precautions within municipal facilities.


required

Thu Jan 20 2022




Player Last Name:

Symptoms should not be chronic or related to other known causes or conditions

1. Are you experiencing a fever or chills?
       

2. Are you suffering from shortness of breath?
        

3. Do you have a cough?
        

4. Are you experiencing loss of smell or taste?
        

5. Are you experiencing nausea, vomiting or diarrhea?
        

6. Are you feeling unwell, tiredness or sore muscles?
        

7. Have you travelled outside of Canada in the last 14 days AND are NOT exempt from federal quarantine requirements?
        

8. Have you had close contact with a person with a respiratory illness OR a confirmed OR suspected case of COVID-19?
        


PLEASE WAIT FOR A RESPONSE AFTER SUBMITTING ANSWERS TO ENSURE THEY WERE RECORDED

THANK YOU


This Health Screening questionaire has been developed based on the current guidelines from the Ontario Ministry of Health


Have you uploaded your vaccination proof and/or negative PCR test document yet?