CovidScreening

SSSC Covid Screening Form

According to public health directives, this form must be completed on the day of the activity. If this activity is in the future please return to complete this form on that day.

Participant information

* Indicates required field

Name *

First

Last

Phone Number *

Skater Name *

Is the participant under the age of 18 *

Yes No

The following information pertains to the participant and the adult/guardian submitting the form

Section # 1 - Symptoms

Are you or your child currently experiencing any of these symptoms?
The symptoms listed here are the symptoms most commonly associated with COVID-19. Our guidelines for children and adults continue to evolve as we learn more about COVID-19, how it spreads, and how it affects people in different ways.
Choose any/all that are new, worsening, and not related to other known causes or conditions they already have.

Fever and/or chills : Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills
Cough or barking cough (croup): Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have)
Shortness of breath : Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have)

Decrease or loss of taste or smell: Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have
(For adults > 18 years or older) Fatigue. lethargy, malaise and/or myalgias : Unusual tiredness, lack of energy
(For children <18 years) Nausea, vomiting and/or diarrhea: Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have

Do any of the above symptoms apply to you or to the participant?

Section #1 - any symptoms of Covid-19 *

No Yes

Section #2 - Screening Questions

1. In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

2. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? This can be because of an outbreak or contact tracing

3. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?

4. In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?

5. In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?

6. In the last 14 days has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

7 In the last 10 days, has someone in your household (someone you live with) been identified as a "close contact" of someone who currently has Covid-19 AND been advised by a doctor, healthcare provider or public health unit to self-isolate ?

8 Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms

Do any of the above conditions or symptoms apply to you and/or the participant

Section #2 - Other screening questions *

No Yes

If you think that you may have been in contact with someone with Covid or have any of the Covid symptoms, please do not enter the facilities.

If you have a second adult attending please have them complete a second form.

Submit