LET'S KEEP OUR COMMUNITY SAFE

PRE-SCREENING QUESTIONNAIRE

Screening Questionnaire

Facility*
Players Name*
First Last
Parents Name*
First Last
Phone*
Email
Date*
MM slash DD slash YYYY
Time*
1. In the last 14 days, have you/the participant travelled outside of Canada?

2. Has a doctor, health care provider, or public health unit told you/the participant that they should currently be isolating (staying at home)?

3. In the last 14 days, have you/the participant been identified as a "close contact" of someone who currently has COVID-19?

4. In the last 14 days, have you/the participant received a COVID Alert exposure notification on your cell phone?

5. Are you/the participant currently experiencing any of these symptoms:
- Fever and/or chills
- Cough or barking cough (croup)
- Shortness of breath
- Decrease or loss of taste or smell
- Sore throat or difficulty swallowing
- Running or stuffy/congested nose
- Headache
- Nausea, vomiting and/or diarrhea
- Extreme tiredness or muscle aches
6. Is anyone that you/the participant lives with currently experiencing new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

Did you answer YES to any of these questions
Did you answer YES to any of these questions?*
- YES
- No

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