EFAC U18 AAA Alberta Health Daily Checklist - ADULT 18 YEARS AND OLDER
Pursuant to the AHS and Hockey Edmonton requirements, this form must be submitted ON THE SAME DATE AS THE ICE TIME/ACTIVITY, and no later than 2 hours prior to that scheduled ice time/activity. Please DO NOT complete the night before as the date will be incorrect and the player will not be allowed to participate.

If an individual answers YES to any of the questions, the person participating in the ice/activity MUST NOT attend or participate in the program.

*Individuals with fever, cough, shortness of breath, runny nose, or sore throat, are required to isolate for 10 days per CMOH Order 05-2020 unless they receive a negative COVID-19 test and are feeling better. Use the AHS Online Assessment Tool to determine if testing is recommended and follow information on isolation requirements.

As the COVID-19 pandemic continues to evolve, this screening tool will be updated as required.

** Face-to-face contact within 2 metres. A health care worker in a occupational setting wearing
the recommended personal protective equipment is not considered to be a close contact.
Email Address *
Player Name *
Date of Ice Time or Activity *
Q1. Does the person attending the ice/activity have ANY new onset or worsening of ANY of the following symptoms: Fever*, Cough*, Shortness of Breath/Difficulty Breathing*, Runny nose*, Sore throat*, Chills, Painful swallowing, Nasal congestion, Feeling unwell/Fatigued, Nausea/Vomiting/Diarrhea, Unexplained loss of appetite, Loss of sense of taste or smell, Muscle/Joint aches, Headache, Conjunctivitis (commonly known as pink eye) *
Q2. Has the person attending the ice/activity traveled outside of Canada in the last 14 days? *
Q3. Has the person attending the ice/activity had close contact** with a confirmed case of COVID-19 in the last 14 days? *
Q4. Has the person attending the ice/activity had close contact with an individual who has any one of the first 5 symptoms in Question 1 AND who is a close contact of a confirmed case of COVID-19 in the last 14 days? *
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