COVID-19 Screening (NDMS) (Norwood Minor Hockey)

Print COVID-19 Screening (NDMS)

TO BE FILLED OUT WITHIN 2-6 HOURS PRIOR TO ARRIVAL AT THE ARENA. MUST BE COMPLETED FOR EVERY ON ICE SESSION - Practice or Game. Please read through the questionnaire and answer all of the questions. Please answer all questions accurately. Players who arrive at activities and appear to be symptomatic will not be allowed to participate. If your player is not feeling well, or showing any signs of any illness please keep them home. If you have any symptoms or answer yes you must stay home for a minimum of 24 hours after the last symptom subsides. You are given 2 options on the form: *PASS - answered "NO" to all questions and players are permitted to participate *FAIL- answered "YES" to any of the questions and players are NOT permitted to participate. Please notify Coach if your child is not attending and the reasons for missing, this is for tracking purposes. You will automatically get an email and will show this to the person filling out the tracking sheet

PLAYER IDENTIFICATION

Please fill in all fields Parent/Guardian - please list the individual who will be entering the arena with player. For players U13 and Under

Email Address^*

Example: [email protected] Your submission will be sent to this address.

Date ^*

Open the calendar popup.

Players Name
Adult Entering Arena with Player - Applies to U13 and under ONLY
Team Staff Member
Team / Affiliation^*

HEALTH SCREENING QUESTIONNAIRE

Answers ALL questions based on the player and parent/guardians health

Difficulty Breathing?^*
YESNO
Sore Throat?^*
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
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

CRITICAL ASSESSMENT

Answer ALL Questions For the remaining questions, close physical contact means: Being less than 2 metres away in the same room, workspace, or area for over 15 minutes 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