COVID-19 Daily Screening
Please complete the below questionnaire prior and on the same day as your visit.

REMINDER – THIS FORM IS ONLY VALID IF COMPLETED ON THE DAY OF YOUR ACTIVITY.

A new form must be completed prior to each entrance to the facility.
Sign in to Google to save your progress. Learn more
Email address * *
Participant Name *
Parent/Guardian Name (if accompanying minor) *
Date of Program/ Ice Session *
MM
/
DD
/
YYYY
Start Time of Program/ Ice Session *
Time
:
Do you (participant and/or spectator) have any COVID-19 symptoms, including fever and/or chills, cough, shortness of breath, sore throat, difficulty swallowing, runny nose or congestion, decrease of taste or smell, pinkeye, headache, digestive issues, muscle aches, extreme tiredness, or falling down often (for older people). *
Is anyone that you (participant and/or spectator) live with currently experiencing COVID-19 symptoms, or is awaiting a test result after experiencing symptoms? *If you are fully vaccinated (2 weeks after completion of last required dose), select "NO" *
In the last 14 days have you (participant and/or spectator) travelled outside Canada? (If exempt from federal quarantine requirements select "NO") *
In the last 14 days, have you traveled outside of Canada or have you close physical contact with a person who has returned from travel outside of Canada? *
In the last 14 days have you (participant and/or spectator) been identified as a close contact of someone who currently has COVID-19? *If you are fully vaccinated (2 weeks after completion of last required dose), and have not been told by Public Health to isolate, select "NO" *
Has a doctor, health care provider, or public health unit told you (participant or spectator) that you should currently be isolating? *
In the last 10 days have you (participant or spectator) tested positive for COVID-19? *If you have since tested negative on a lab based PCR test, select "NO" *
In the last 14 days, have you (participant or spectator) received a COVID Alert exposure notification on your cell phone? *If you are fully vaccinated (2 weeks after completion of last required dose), or you have tested negative select, "NO" *
By agreeing, I acknowledge that if at any time after submission of my form and my actual ice session that if my health situation with respect to COVID has changed I will refrain from attending the session. *
By agreeing, I acknowledge that all information provided above is accurate and I have agreed to follow the policies and procedures put in place by the Sensplex facilities upon entering the building. *
If you answered YES to any of the screening questions above, go home & self-isolate right away. Visit OttawaPublicHealth.ca/Coronavirus for more information as you may be eligible for a COVID-19 test.If feeling unwell, contact your health care provider or call Telehealth Ontario at 1-866-797-0000 to speak to a registered nurse.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms