OCMHA COVID ASSESMENT

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Please complete the following Screening Questionnaire on the day of and prior to arriving at the session (Game/Practice). If an individual answers “Yes” to any of these questions, they are not permitted to participate in any HEO sanctioned activities and it is recommended that the Ontario COVID-19 self-assessment: https://covid-19.ontario.ca/self-assessment/ for adults and Ottawa Public Health COVID-19 screening tool for Students: https://secureforms.ottawapublichealth.ca/School-Health-Sante-scolaire/COVID-19-Screening-Tool-for-Students. be consulted for further guidance.

Please note: This Health Screening questionnaire has been developed based on the current
Ontario Ministry of Health Self-Assessment Tool.

Email *

Participant (first and last name) *

Parent or guardian accompanying player to practice (first and last name).

Parent or Guardian Phone Number *

POD/Bubble *

Arena *

Ice time *

Has your child (or parent/guardian accompanying child) traveled outside of Canada in the last 14 days? *

Yes

Please note, close physical contact means:

Living in the same home while that person was not self-isolating and infectious

Being less than 2 metres away in the same room or area from another person or unprotected contact for more than 15 minutes

Has your child (or parent/guardian accompanying child) been in close physical contact with someone who has tested positive for COVID-19 in the past 14 days? *

Yes

In the last 14 days has your child (or parent/guardian accompanying child) been in close physical contact with someone who returned from outside of Canada in the last 2 weeks with new COVID-19 symptoms (like a cough, fever, or difficulty breathing)? *

Yes

Has your child’s household contacts (family members and/or roommates) or other contacts outside of school/child care presented with new COVID-19 symptoms (like a cough, fever, or difficulty breathing) in the last 14 days *

yes

Does your child (or parent/guardian accompanying child) have any of the following symptoms that are NOT related to other known causes or conditions *

Fever ( temperature 37.8°C/100.0°F or higher);

Chills

Cough (more than usual if chronic cough) including croup (barking cough, making a whistling noise when breathing) not related to other known causes or conditions; (for example, asthma, reactive airway)

Shortness of breath (dyspnea, out of breath, unable to breathe deeply, wheeze, that is worse than usual if chronically short of breath) not related to other known causes or conditions (for example, asthma)

Decrease or loss of smell or taste (new olfactory or taste disorder) not related to other known causes or conditions, (for example, nasal polyps, allergies, neurological disorders);

No Symptoms

Required

Does your child have any of the following symptoms that are new, worsening, and NOT related to other known causes or conditions

Sore throat (painful swallowing or difficulty swallowing) not related to other known causes or conditions; (for example, post nasal drip, gastroesophagal (acid) reflux);

Stuffy nose and/or runny nose,(nasal congestion and/or rhinorrhoea) not related to other known causes or conditions (for example seasonal allergies, returning inside from the cold, chronic sinusitis unchanged from baseline, reactive airways);

Headache that is new and persistent, unusual, unexplained, or long-lasting not related to other known causes or conditions (for example, tension-type headache, chronic migraines);

Nausea, vomiting and/or diarrhea, not related to other known causes or conditions (transient vomiting due to anxiety in children, chronic vestibular dysfunction, irritable bowel syndrome, inflammatory bowel disease, side effect of medication)

Fatigue, lethargy, muscle aches or malaise (general feeling of being unwell, lack of energy, extreme tiredness, poor feeding in infants) that is unusual or unexplained, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction, anemia);

No Symptoms

If a player or guardian answers “Yes” to any of these questions or has any symptoms noted above, they are not permitted to participate in any HEO sanctioned activities and it is recommended that the Ontario COVID-19 self-assessment for adults and Ottawa Public Health COVID-19 screening tool for students be consulted for further guidance.

Click Submit to complete the form. This will also automatically notify your safety coordinator.

Ontario COVID-19 self-assessment : https://covid-19.ontario.ca/self-assessment/

Ottawa Public Health COVID-19 screening tool for students: https://secureforms.ottawapublichealth.ca/School-Health-Sante-scolaire/COVID-19-Screening-Tool-for-Students

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