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

SELF ASSESSMENT

Are you currently experiencing any one of the symptoms below that are NEW or WORSENING? Symptoms should not be chronic or related to other known causes or conditions

DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS?^*
YESNO
LIST OF SYMPTOMS - CHECK ANY THAT APPLY
Fever and/or Chills
Cough or barking cough (croup)
Shortness of Breath
Sore throat
Difficulty Swallowing
Drecrease or loss of taste or smell
Pink Eye
Runny or stuffy/congested nose
Headache
Digestive issues like nausea, vomitting, diarrhea, stomach pain
Muscle Aches
Extreme tiredness
Check any that apply

CRITICAL ASSESSMENT

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

Has a doctor or health care provider or public health unit told you that you should currently be isolating?^*
YESNO
In the last 14 days , have you been identified as a "close contact"of someone who currently has COVID-19?^*
YESNO
In the last 14 days, have you received a COVID alert exposure notification on your cell phone?^*
YESNO
Has anyone in your household been told to self isolate or to quarantine, or anyoone who is waiting for a COVID test result? If there is we ask you do not enter the arena^*
YESNO
In the last 14 days, have you travelled outside of Canada? (If you are exempted from federal quarantine s Quarantine Act- select NO)
YESNO

SCREENING RESULTS

IF YOU ARE ABLE TO ANSWER "NO" TO ALL QUESTIONS YOU MAY ENTER IF YOU ANSWERED "YES" THEN YOU SHOULD NOT PARTICIPATE UNTIL YOU HAVE CONTACTED A HEALTH OFFICIAL OR YOUR HEATH CARE PROVIDER WE WOULD ALSO LIKE TO REMIND YOU THAT IF ANYONE IN YOUR HOUSEHOLD HAS BEEN ASKED BY THE HEALTH UNIT TO SELF ISOLATE/QUARANTINE THAT YOU NOT PARTICIPATE UNTIL THAT PERSON HAS A NEGATIVE RESULT.

PASS - You answered NO to all questions above
PASS
Check only the one that applies
FAIL - You answered YES to any of the questions listed above. We ask that you do not participate until you have spoke with your health care provider or a health official
FAIL
Check only if applies