COVID 19 Screening (Keene Wolverines)

Print COVID 19 Screening

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 confirmation to be shown at entry

Player Identification

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

YOUR EMAIL - A response will be sent to this address for you to show upon entry^*

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

Date^*

Open the calendar popup.

Wolverines Player Name

Time of Ice usage^*

Open the time view popup.

Adult/Guardian Entering with player
Other Exec/Referee/Coach/Trainer
PICK ONE^*
Playing AWAY Game - Indicate oppposition

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 - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Cough or barking cough - Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
Shortness of Breath - Not related to asthma or other known causes or conditions you already have
Decrease or loss of smell or teste - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
(For children <18yrs) Nausea, vomitting and/or diarrhea - Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have
For adult >18yrs Fatigue, lethargy, malaise and/or myalgiasUnusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have) If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”
Check only if applies

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

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?^*
YESNO
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. ^*
YESNO
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.” ^*
YESNO
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? If you have already gone for a test and got a negative result, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."^*
YESNO
In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit? If you have since tested negative on a lab-based PCR test, select “No.”^*
YESNO
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) in the last 14 days? If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
YESNO
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 advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days? If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
YESNO
. Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
YESNO
If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”

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
PASS
Check only if 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
FAIL
Check only if applies

Human Validation

Check The Box ^*

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Sat Sep 18, 2021

Printed from keenewolverines.com on Saturday, September 18, 2021 at 10:51 AM