Rogues Rugby Covid-19 Attestation Activity Form
As per the BC CDC and BC Rugby ReStart guidelines, please complete the following questionnaire and provide your name and number for contact tracing, should an outbreak occur.
Sign in to Google to save your progress. Learn more
Are you experiencing any of the following:
-Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)
-Severe chest pain
-Having a very hard time waking up
-Feeling confused
-Losing consciousness *
Are you experiencing any of the following:
-Mild to moderate shortness of breath
-Inability to lie down because of difficulty breathing
-Chronic health conditions that you are having difficulty managing because of difficulty breathing *
Check off “yes” to all of the symptoms you are experiencing right now
Select the symptoms you have. If you are not experiencing any symptoms, select "None of the above." *
Required
Have you recently (within 2 weeks) received a new COVID-19 test result?Please enter the date and result of your last COVID-19 test, or write “no” “not applicable” or “n/a”
*
Have you returned to Canada from any country (including the United States) within the last 14 days? *
Did you have close contact with a person with confirmed COVID-19 within the last 14 days?
A close contact is someone confirmed to have COVID-19 who you live with or otherwise had close face to face contact (within 2 metres) while they had symptoms or in the 48 hours before their symptoms started.

Note: This means you would have been contacted by your health authority’s public health team. *
Your phone number (to be used for official contact tracing purposes only) *
I the undersigned, attest the above answers to be true and will not participate in todays club activity if I have answered “yes” to any of the above questions. (write your name) *
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