COVID-19 SCREENING FORM (Port Dover Minor Hockey)
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COVID-19 SCREENING FORM
CONTACT INFORMATION
Email address
*
A receipt of this submission will be sent to the email address provided. This receipt must be shown at the arena door to gain entry.
Telephone number
*
Example: ###-###-####
COVID-19 SCREENING QUESTIONNAIRE
Select date and time of activity
*
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
<<
<
June 2022
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<<
June 2022
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Open the time view popup.
Time picker
Time Picker
12:00 AM
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
11:00 PM
Exact times can be typed if not available on the time picker.
Enter name of participant
*
Select location of activity
*
Port Dover Arena
Waterford Tricenturena
Simcoe Talbot Gardens
Delhi Arena
Langton Arena
Do you have a fever greater than or equal to 38°C (100.4°F) and/or a new onset of cough or difficulty breathing?
*
Yes
No
Have you returned from travel outside of Canada in the past 14 days?
*
Yes
No
Arrival date of your return to Canada?
RadDatePicker
RadDatePicker
Open the calendar popup.
Calendar
Title and navigation
Title and navigation
<<
<
June 2022
>
<<
June 2022
S
M
T
W
T
F
S
23
29
30
31
1
2
3
4
24
5
6
7
8
9
10
11
25
12
13
14
15
16
17
18
26
19
20
21
22
23
24
25
27
26
27
28
29
30
1
2
28
3
4
5
6
7
8
9
Not required if you have not travelled outside of Canada in the previous 14 days.
Have you been asked to self-isolate?
*
Yes
No
Have you been in close contact with or had unprotected exposure to a confirmed or probable case of COVID-19
*
Yes
No
Have you had close contact with or had unprotected exposure to any person with an acute respiratory illness who has returned from travel outside of Canada with the past 14 days prior to their illness onset?
*
Yes
No
Human Validation
Check The Box
*
Human Validation Failed, Please Try Again
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Printed from pdmha.com on Sunday, June 26, 2022 at 1:49 PM
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