Health Screening Questionnaire
Daily Health Screening
Orono Figure Skating Club
This questionnaire must be completed by each individual prior to participation in each activity.
The answer to all questions must be “No” in order to participate in each on-ice activity. Spectator answer's must be "No" in order to enter the arena.
Skater FIRST Name *
Skater LAST Name *
Spectator FIRST Name
Spectator LAST Name
Today's Date *
MM
/
DD
/
YYYY
Cell Phone # - **Please give the cell # of the person who will be picking up the skater. *
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? *
Yes
No
Cough (that’s new or worsening)
Shortness of breath
Runny, stuffy or congested nose (not related to other known causes such as seasonal allergies etc.)
Sore throat
Difficulty swallowing
Lost sense of taste or smell
Have you travelled outside the province in the past 14 days or been in close contact with someone who has travelled outside the province in the past 14 days? *
Have you had close contact in the past 14 days with anyone with a new cough, fever or difficulty breathing or a confirmed case of COVID-19?
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