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

1 FORM PER FAMILY Parent/Guardian - PLEASE LIST the individual who will be entering the arena with player.

Email Address^*

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

Date ^*

Open the calendar popup.

Hornets Players Name
Adult/Guardian Entering Arena with Player
OTHER - Coach/Exec/ Referee/Timekeeper
Pick One ^*
Playing AWAY GAME - indicate which center/arena

HEALTH SCREENING Part 1

Do you have any ONE of the following symptoms?

Shortness of Breath^*
YESNO
Decreased/Lost sense of taste or smell ^*
YESNO
Fever/Chills (37.8 or higher, feeling hot to the touch)^*
YESNO
Cough that’s new or worsening (continuous, more than usual)^*
YESNO

HEALTH SCREENING Part 2

Do you have any 2 or MORE of the following symptoms that is new OR persistent or worsening?

Sore Throat^*
YESNO
Stuffy/Runny Nose^*
YESNO
Headache^*
YESNO
Nausea^*
YESNO
Diarrhea^*
YESNO
FAtigue, Lethargy, Muscle Aches or Malaise^*
YESNO
Vomitting^*
YESNO
If YES to any ONE primary or any 2 secondary symptoms - Have you had a negative COVID 19 swab and symptoms improving in the last 24 hours?^*
YESNONot Applicable

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

Have you been in close physical contact with someone who tested positive for COVID-19?^*
YESNO
If YES, have you had 2 negative COVID 19 swabs at least 5 days apart?^*
YESNONot Applicable
Have you had close physical contact with someone who has travelled outside Canada in the last 14 days? Close contact being less than 2 meters away in the same room/house?^*
YESNO
If YES, are they exempt (as per health canada) from quarantine or has been 14 days passed and symptom free? ^*
YESNONot Applicable