Daily Assessment: Covid Contact Tracing and Sign In

To provide a safe environment for the Hoop Factory Community, we require you to fill out the following questionnaire to help determine your fitness to work or learn during the COVID-19 pandemic.

The information in this questionnaire is collected under the authority of FOIP section 33 (3) and will be used and disclosed solely for the purpose of determining fitness to work or learn during the COVID-19 pandemic.

You must follow social distancing, face covering, and hand hygiene protocols and remember to clean your keys, phone, computer and other personal items.

The questionnaire only relates to new symptoms or a worsening of symptoms related to allergies, chronic or preexisting conditions. Those with symptoms related to pre-existing conditions or allergies can still participate.
Email address *
First and Last Name *
Todays Date *
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You are an *
By completing this assessment I confirm my health and agree to follow Hoop Factory protocols related to COVID-19, including wearing a face covering as required, following physical distancing and following good hygiene practices. *
Do you have any of the following symptoms which are new? Or, if these symptoms are normally associated with allergies, chronic or pre-existing conditions, have they worsened? - fever - cough - shortness of breath- difficulty breathing- sore throat- runny nose or stuffy nose- muscle or joint aches- feeling unwell, fatigue or severe exhaustion- nausea- vomiting- diarrhea- loss of appetite *
Do you have any of the following symptoms which are new? Or, if these symptoms are normally associated with allergies, chronic or pre-existing conditions, have they worsened? - fever - cough - shortness of breath- difficulty breathing- sore throat- runny nose or stuffy nose- muscle or joint aches- feeling unwell, fatigue or severe exhaustion- nausea- vomiting- diarrhea- loss of appetite *
Have you returned to Canada from outside the country (including USA) in the past 14 days? *
Have you had close contact with a person who is a confirmed case of COVID-19? *
Have you had close contact with a person showing symptoms above who returned from travel outside of Canada in the 14 days before they became sick? *
If you answer “YES” to any of the above, you are not permitted to attend sessions or rentals at this time and you must self-isolate. Complete the Self-Assessment Tool at:https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-coronavirus/covid-19-self-assessment or https://myhealth.alberta.ca/journey/covid-19/Pages/COVID-Self-Assessment.aspx to determine your need for COVID-19 testing. Please inform Chris King directly.
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If you answer “NO” to all of the above, you can proceed on site at Hoop Factory. If you develop any of the above symptoms, please complete a new questionnaire. Note: If you have any other symptoms which are new or a change from your usual symptoms, then you should stay home and minimize contact with others until you are feeling better.
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A copy of your responses will be emailed to the address you provided.
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