NASC Tyke - COVID-19 Pre-Screening Questionnaire (OHF)
This survey will take approximately 4 minutes to completed.

IMPORTANT: THIS MUST BE COMPLETED ON THE SAME DAY AS YOUR SCHEDULED ACTIVITY

If you Answer "YES" to any of the questions, you are NOT to attend your session. Thank you.
Email *
Team Name *
Player Name *
Date of Activity *
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DD
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Time of Activity *
Facility *
Do you have a fever? *
Chills? *
Cough that is new or worsening (continuous, more than usual)? *
Barking cough, making a whistling noise when breathing (croup)? *
Shortness of breath (out of breath, unable to breathe deeply)? *
Runny nose, sneezing or nasal congestions (Not related to seasonal allergies or other known causes or conditions)? *
Lost sense of taste or smell? *
Pink eye (conjunctivitis)? *
Headache that's unusual or long lasting? *
Digestive issues (nausea/vomiting, diarrhea, stomach pain)? *
Muscle aches, extreme tiredness this is unusual (fatigue, lack of energy)? *
In the past 14 days, have you had close physical contact with someone who has tested positive for COVID-19? [Close physical contact means 1) being less than 2 meters away in the same room, workspace of area for over 15 minutes; 2) living in the same home.] *
In the past 14 days, have you been in close physical contact with a person who is either: currently sick with a new cough, fever, or difficulty breathing (acute respiratory illness); OR, Returned from outside Canada in the last 14 days. (Essential workers who cross the Canada-US border regularly are exempted) [Close physical contact means 1) being less than 2 meters away in the same room, workspace of area for over 15 minutes; 2) living in the same home.] *
Have you travelled outside of Canada in the last 14days? (Essential workers who cross the Canada-US border regularly are exempted) *
In the past 14 days have you been directed by Public Health to self-isolate? *
Name of Parent/Guardian staying in the arena, if applicable. This does not include the coaching staff. Enter NA if no parent/guardian staying. *
Your Phone/Cell Number *
As a parent / guardian or team representative, do any of the above pre screening questions apply to yourself? (Answer NO if you have no symptoms) *
A copy of your responses will be emailed to the address you provided.
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