Gloucester Concordes Speed Skating Club COVID-19 Health Screening Questionnaire
Each individual must complete this questionnaire each time in order to participate in any Gloucester Concordes Speed Skating Club activities.

Please submit this questionnaire up to three hours before your arrival at the arena.

Our designated Covid Officer will receive your responses and will double check again upon arrival. You may also submit a paper copy of this questionnaire located on our website.
https://gloucesterconcordes.ca/images/files/PDF/COVID_2020/GCSSC_Health_Screening_Questionnaire.pdf
Email *
Members Name *
Phone Number *
Today's Date *
MM
/
DD
/
YYYY
Please select the club activity you are attending? *
The answer to all questions must be "No" in order to participate in club activities.
Do you have chills or a fever (feeling hot to touch, a temperature of 37.8C or higher)? *
1 point
Do you have a cough, barking cough (new or worsening)? *
1 point
Do you have trouble breathing, shortness of breath? *
1 point
Do you have a runny nose, sneezing or stuffy or congested nose? (not related to seasonal allergies) *
1 point
Do you have a sore throat? *
1 point
Do you have difficulty swallowing?
1 point
Clear selection
Decrease or lost your sense of taste or smell?
1 point
Clear selection
Do you have any eye infections, such as Pink eye? *
1 point
Any headaches that is unusual or long lasting? *
1 point
Any digestive issues like nausea/vomiting, stomach pain or diarrhea? *
1 point
Any Muscle aches that are unusual or long lasting? *
1 point
Any extreme tiredness that is unusual? *
1 point
In the last 14 days, have you been identified as a close contact of someone who currently has COVID-19? This includes getting a COVID Alert exposure notification. *
1 point
Have you travelled outside of Canada or had close contact with anyone that has travelled outside of Canada in the past 14 days? *
1 point
Have you had close contact in the past 14 days with anyone with a new cough, fever or difficulty breathing or a confirmed case of COVID-19? *
1 point
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