GameOn Sports Official's COVID-19 Daily Assessment Tool
Senior Men's 4 On 4 Ball Hockey League 2020-2021 Season
Complete and submit the following Daily Assessment Questionnaire prior to entering the facility.
The questions are relevant to the official, and all members of the family "bubble'. You should refrain from entering the facility if you or any member of your family "bubble" are experiencing potential COVID-19 symptoms.
This information is being collected with your consent and in accordance with PIPEDA for the purpose of compliance with the directives of the Chief Medical Officer of Health of Newfoundland and Labrador in response to the COVID-19 Public Health Emergency.
By completing this form you consent to the collection, use and disclosure of this information as directed by the Chief Medical Officer of Health or as required by law. This information will be stored securely by GameOn Sports for 14 days from the date the form was completed, after which time it will be deleted.
Upon request, this data will also be made available to the NLBHA and the Northpoint Sports Facility.
Official's First and Last name:
Do you have a fever and/or cough (new or worsening)?
Do you have two or of the following symptoms (new or worsening)?
Sore throat or difficulty swallowing
Unusual fatigue or lack of energy
New onset of muscle aches
Unexplained loss of appetite
Vomiting or Diarrhea
Loss of sense of smell or taste
Runny, stuffy or congested nose
Small red or purple spots on your hands and/or feet
NONE OF THE ABOVE
Have you been in close contact with a known or suspected case of COVID-19 (probably or confirmed) within the last 14 days?
Have you or anyone in your household traveled outside the Atlantic Canadian bubble within the last 14 days? (New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador) or outside the communities along the Labrador-Quebec border?
Travel includes passing through an airport.
If you answered YES to any of the previous questions DO NOT PROCEED TO FACILITY. Remain at home and self-isolate. Visit
or call 811. If you responded NO to all questions, you may proceed to facility.
Liability Waiver - check each box to acknowledge that you have read and understand each statement.
Please check each box to acknowledge that you have read and understand each statement. If you do not understand each statement, please contact us at
I acknowledge the contagious nature of COVID-19 and agree to adhere to distancing guidelines recommended by public health officials
I acknowledge COVID-19 exposure/infection may result from the actions of myself, others and their families
I agree to follow all safety precautions outlined by GameOn Sports, and governing sport bodies
I acknowledge GameOn Sports cannot guarantee that I will not become infected with COVID-19
Send me a copy of my responses.
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