Bowmanville FSC Daily Health Screening Questionnaire (Updated February 2021)
Must be submitted each day of skating
Must be completed prior to arriving at the Arena
Must be completed by all Skaters and Participants.
The Answer to all questions must be "No" in order to participate in each on-ice activity.
Email address *
This form is for the following: *
Skaters or Coach or Parent Name (each need an individual form submitted) *
Date of Session *
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Contact phone number
1. Do you have a fever? (Feeling hot to the touch, a temperature of 37.8C or higher) *
Do you have any of the following symptoms? 2. Cough (continuous, more than usual) *
3. Shortness of breath *
4. Runny nose, sneezing or nasal congestion (not related to other known causes such as seasonal allergies etc.) *
5. Sore Throat *
6. Difficulty Swallowing *
7. Lost sense of taste or smell *
8. Have you travelled outside of Canada in the past 14 days or had close contact with anyone that has travelled outside of Canada in the past 14 days does not have a Government of Canada Travel Exemption*? *
9. Have you had close contact in the past 14 days with anyone with active respiratory illness or an active confirmed or probable case of COVID-19? *
Please note: This Health Screening questionnaire has been developed based on the current Ontario Ministry of Health Self-Assessment Tool.
*For information on Travel Exemptions to the emergency order of the Government of Canada's Quarantine Act, please go to : http://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/latest-travel-health-advice.html#a3
A copy of your responses will be emailed to the address you provided.
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