Health Screening Questionnaire | Wildcats Volleyball Club

Date (dd/mm/yr) *

Name *

First

Last

Phone *

Email *

SECTION 1

1. Are you currently experiencing any of these issues? Call 911 if you are. *

Severe difficulty breathing (struggling for each breath, can only speak in single words) • Severe chest pain (constant tightness or crushing sensation) • Feeling confused or unsure of where you are • Losing consciousness

2. Are you currently experiencing any of these symptoms? *

***Fever – Temperature of 37.8 degrees Celsius – 100 degrees Fahrenheit or higher, ***Chills, ***Cough that’s new or worsening – Continuous, more than usual, not related to other known causes or conditions (for example, COPD), ***Barking cough, making a whistling noise when breathing – Croup, not related to other known causes or conditions, ***Shortness of breath – Out of breath, unable to breathe deeply, not related to other known causes or conditions (for example, asthma), ***Sore throat – Not related to other known causes or conditions (for example, seasonal allergies, acid reflux, ***Difficulty swallowing – Painful swallowing, not related to other known causes or conditions, ***Runny nose – Not related to other known causes or conditions (for example, seasonal allergies, being outside in cold weather), ***Stuffy or congested nose – Not related to other known causes or conditions (for example, seasonal allergies), ***Decrease or loss of taste or smell – Not related to other known causes or conditions (for example, allergies, neurological disorders), ***Pink eye – Conjunctivitis, not related to other known causes or conditions (for example, reoccurring styes), ***Headache that’s unusual or long lasting – Not related to other known causes or conditions (for example, tension-type headaches, chronic migraines), ***Digestive issues like nausea/vomiting, diarrhea, stomach pain – Not related to other known causes or conditions (for example, irritable bowel syndrome, anxiety in children, menstrual cramps), ***Muscle aches that are unusual or long lasting – Not related to other known causes or conditions (for example, a sudden injury, fibromyalgia), ***Extreme tiredness that is unusual – Fatigue, lack of energy, not related to other known causes or conditions (for example, depression, insomnia, thyroid disfunction), ***Falling down often – For older people, ***Sluggishness or lack of appetite – For young children and infants

3. In the last 14 days, have you been in close physical contact with someone who currently has COVID-19? Note: This includes getting a COVID Alert exposure notification. *

***Close physical contact means: • being less than 2 metres away in the same room, workspace, or area • living in the same home • being in the same classroom

4. In the last 14 days, have you been in close physical contact with someone who is currently sick with a new cough, fever, difficulty breathing, or other symptoms associated with COVID-19? *

***Close physical contact means: • being less than 2 metres away in the same room, workspace, or area • living in the same home • being in the same classroom

5. Have you travelled outside of Canada in the last 14 days? Note: This does not include essential workers who cross the Canada-US border regularly. *

***If an individual answers “yes” to any of the questions in section one (1), they are not permitted to participate in any club or OVA activity.

Section 2 The answer to question 1 in Section 2 must be “No” or you must have clearance from your local public health unit to participate in club or OVA activity.

1. In the last 14 days, have you been in close physical contact with someone who has returned from outside of Canada? Note: This does not include essential workers who cross the Canada-US border regularly. *

***Close physical contact means: • being less than 2 metres away in the same room, workspace, or area • living in the same home • being in the same classroom *If answered yes to this question, before participating you must check with your local public health unit to find out if there are any other actions you need to take (e.g. 14-day self isolation) before resuming club or OVA activity.

2. If answered yes to question 1, I have contacted my local public health unit and have received clearance to participate in volleyball activities. *

***Note: We recommend that you pay extra attention to your health and note if anything changes because you were in close physical contact with someone who has recently travelled.

If an individual answers “yes” to any of these questions, they are not permitted to participate in any club activities.