COVID-19 Daily Health Monitoring Questionnaire and Attestation

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A separate Daily Health Monitoring Questionnaire and Attestation must be completed by each athlete and by any parent or guardian attending with an athlete prior to each training session or event and prior to entering the training environment. Children and youth will need a parent to assist them in completing this screening tool.
note: updated to Version 2, July 27, 2020.

Email *

Name of Athlete or Parent/Guardian: *

1. Does the activity participant have any of the following symptoms relative to their normal personal baseline? *

Cough (new, worsening, continuous, or barking) *

Shortness of Breath / Difficulty Breathing *

Sore Throat *

Chills *

Painful or Difficulty Swallowing *

Runny nose / Nasal Congestion *

Feeling unwell / Extreme fatigue *

Nausea *

Vomiting / Diarrhea *

Unexplained loss of appetite *

Loss of Sense of Taste or Smell *

Muscle / Joint Pain *

Headache *

Conjunctivitis ( Pink Eye ) *

If you answered “YES” to two or more of the symptoms, DO NOT enter the training environment.If you answered “YES” to any of fever, diarrhea, OR vomiting, DO NOT enter the training environment.Go home immediately and use the BC COVID-19 Self-Assessment Tool or contact Health Link at 8-1-1, or your primary care provider to determine if further assessment and/or COVID-19 testing is recommended.

2. Have you, or has anyone in your household, travelled outside of Canada in the last 14 days? *

Yes

3. Have you, or has anyone in your household, travelled in the last 14 days, to a location identified by the Provincial Health Office or Government of BC as currently experiencing a community COVID-19 outbreak? *

Yes

4. Have you, or has anyone in your household, within the last 14 days, had close contact, resided with, or cared for someone without protection who is ill with a cough and/or fever? *

Yes

5. Have you, or anyone in your household, within the last 14 days, had close contact, resided with, or cared for someone without protection who has or is suspected to have COVID-19? *

Yes

6. Have you been notified by a public health authority or healthcare provider that you, or anyone in your household, may have been exposed to COVID-19 and/or that you should self-isolate? *

Yes

7. Have you been diagnosed with a suspected or confirmed case of COVID-19 and are you still experiencing symptoms? *

Yes

8. Have you been diagnosed with a suspected or confirmed case of COVID-19 and has it been less than 14 days since the later of your diagnosis or the ending of your symptoms, if any? *

Yes

If you answered “NO” to questions 2-8, you may enter the training environment after completing the following ATTESTATION:

I, ( enter name of athlete / participant below ), agree that: *

while participating in any training session, event, or when attending the training facility, I will, to the best of my ability, follow the laws, recommended guidelines, and protocols issued by the Government of BC in respect of COVID-19, including practicing physical distancing; ( enter initials below in the box ) *

while participating in any training session, event, or when attending the training facility, in the event that I experience any symptoms of illness such as fever, cough, difficulty breathing, shortness of breath, or malaise, I will immediately:• inform a representative of the Organization; and• depart from the event or facility; ( enter initials below in the box ) *

if I have ever been diagnosed with a suspected or confirmed case of COVID-19, I will provide the Organization with written confirmation that I am noncontagious by a medical doctor before I participate in or attend any training session or event or enter the training environment; and ( enter initials below in the box ) *

my answers to the questions in the Health Monitoring Questionnaire are true. In the box below enter athlete name and date of birth, parent name and date signed. By entering your information below you are signing this document. *

Send me a copy of my responses.

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