The Dugout COVID-19 Assessment Form
If you answer "yes" to any of the following Questions, you should not enter the facility. You should go home or stay home to self-isolate immediately and contact your healthcare provider, or Telehealth Canada
(1-866-797-0000) to find out if you need a COVID-19 test
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Name (First and Last) *
Do you have a fever and/or chills? Temperature of 37.8 degrees Celsius or higher? *
Cough or barking cough - continuous, more than usual, making a whistling noise when breathing not related to other cause or conditions such as asthma? *
Shortness of breath/ unable to breathe deeply, not related to any known causes or conditions
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Decrease or loss of smell or taste, not related to other cause of conditions *
Sore throat or difficulty swallowing- painful swallowing, not related to other cause or conditions *
Runny, stuffed or congested nose not related to any other cause or condition. *
Headache that's unusual or long lasting, not related to other cause or conditions *
Nausea, vomiting or diarrhea, not related to other known causes or conditions. *
Extreme tiredness that is unusual or muscle aches- fatigue, lack of energy not related to other causes or conditions *
Have you ore someone from your household travelled outside of Canada in the last 14 days? If you are an essential worker who crosses the Canada-US border regularly for work, please select "No" *
In the Last 14 days, has a public health unit identified you or someone in your house as a close contact of someone who currently has COVID-19 *
Has a doctor, healthcare provider, or public health unit told you that you or someone from your household should currently be isolating? *
In the Last 14 days, have you or someone from your household received COVID Alert Exposure notification on your cell? If you already went for your test and got a negative result, select "No" *
I acknowledge the contagious nature of COVID-19 and that the public health authorities still recommend practicing social distancing. I further acknowledge that The Dugout Baseball and Softball Academy has put in place preventative measures to reduce the spread of COVID-19. I further acknowledge that The Dugout Baseball and Softball Academy can not guarentee that I will not become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by COVID-19 may result from the action, omissions, or negligence of myself and others, including but not limited to, facility staff, and other clients and their families. I voluntarily seek services provided by The Dugout Baseball and Softball Academy and acknowledge that I am increasing my risk of exposure to COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending all in person practice/training. *
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