COVID Screening (Whitby Girls Hockey Association)
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COVID Screening
Participant
Name
*
email
*
[email protected]
A confirmation will be emailed to you
Role
*
Select One...
Ref
Timekeeper
Provider
If other please specify
Arena
*
Select One...
IPSC Pad 1
IPSC Pad 2
IPSC Pad 3
IPSC Pad 4
IPSC Pad 5
IPSC Pad 6
McKinney Pad 1
McKinney Pad 2
if other please specify:
Date
*
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
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Start Time
*
RadDatePicker
RadDatePicker
Open the time view popup.
Time picker
Time Picker
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What time is the first game or practice
Until
*
RadDatePicker
RadDatePicker
Open the time view popup.
Time picker
Time Picker
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
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11:00 PM
Please enter the end of the last game or practice
1. Are you experiencing any of these symptoms?
The answer to all questions must be "No" in order to participate in each on-ice activity.
Do you have a fever?
*
No
Yes
Feeling hot to the touch, a temperature of 37.0C or higher
Chills
*
No
Yes
Cough that's new or worsening
*
No
Yes
Continuous, more than usual
Barking cough, making a whistling noise when breathing
*
No
Yes
Croup
Shortness of Breath
*
No
Yes
Out of breath, unable to breathe deeply
Sore Throat
*
No
Yes
Difficulty Swallowing
*
No
Yes
Runny nose, sneezing or nasal congestion
*
No
Yes
not related to seasonal allergies or other known causes or conditions
Lost sense of taste or smell
*
No
Yes
Pink Eye
*
No
Yes
conjunctivitis
Headache that's unusual or long lasting
*
No
Yes
Digestive issues
*
No
Yes
Nausea/vomiting, diarrhea, stomach pain
Muscle Aches
*
No
Yes
Extreme tiredness that is unusual
*
No
Yes
fatigue, lack of energy
Falling down often
*
No
Yes
For young children and infants: sluggishness or lack of appetite
*
No
Yes
Remaining Questions
For the remaining questions, close physical contact means: Being less than 2 meters away in the same room, workspace, or area for over 15 minutes or living in the same home.
2. In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?
*
No
Yes
3 In the last 14 days, have you been in close physical contact with a person who either: Is currently sick with a new cough, fever, or difficulty breathing; OR Returned from outside of Canada in the last 2 weeks?
*
No
Yes
4. Have you travelled outside of Canada in the last 14 days?
*
No
Yes
Human Validation
Check The Box
*
Human Validation Failed, Please Try Again
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