Active Screening Questionnaire
Active Screening is a health review for all participants. Completing Active Screening is a mandate of the Ministry of Health and Ottawa Public Health for participation in Summer Sports programs. Submitting this Questionnaire makes it easy for you to comply.
It helps everyone remain safe and healthy!
Information collected will only be used by the Manor Park Community Council (MPCC) for the administration and management of 'Physically Active and Physically Distanced Programs' and will only be shared if legally required.
Do you have one or more of the following symptoms? Check all that apply.
Fever (37.8 degrees C or higher)
Cough that's new or worsening (continuous, more than usual)
Barking cough, making a whistling noise when breathing (croup)
Runny, stuffy, or congested nose (not associated with allergies or other known condition)
Lost sense of taste or smell
Pink eye (conjunctivitis)
Headache that's unusual or long-lasting
Digestive issues (nausea / vomiting, diarrhea, stomach pain)
Extreme tiredness that is unusual (fatigue, lack of energy)
Falling down often
Sluggishness or lack of appetite
None of the above
Do you have an inflammatory condition? Check all that apply. NOTE: A doctor's note is required to return to the program.
Abnormal swelling in the hands or feet that requires medical attention
None of the above
I attest that: I have NOT travelled outside of Canada (including the United States) in the last 14 days; I have NOT had close contact with a confirmed or probable Covid-19 case, and I have NOT had close contact with a person with acute respiratory illness who has been outside of Canada (including the United States) in the last 14 days.
Yes, I attest.
No, I do not attest.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service