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COVID DECLARATION for KW Water Polo

Pre-screening Questionnaire

This declaration must be completed at least one hour before, and on the day of the practice that participant(s), and anyone else accompanying the participant and entering the facility, plans to attend. The names of ALL people entering the facility must be entered on this form, or a separate form must be completed.

Criteria updated based on Ontario's Office of the Chief Medical Officer of Health COVID-19 Screening Tool for Businesses and Organizations - Version 8 – August 27, 2021

Please review the following questions and consider whether any of the people planning on entering the facility would answer yes to any of the following:
 
  • Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.
    • Fever and/or chills?
      • Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
    • Cough or barking cough (croup)?
      • Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have
    • Shortness of breath?
      • Not related to asthma or other known causes or conditions you already have
    • Decrease or loss of smell or taste?
      • Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
    • For adults > 18 years or older: Fatigue. lethargy, malaise and/or myalgias?
      • Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
      • If you received a COVID-19 vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.”
    • For children < 18 years: Nausea, vomiting and/or diarrhea?
      • Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions you already have
  • In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?
  • Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
    • This can be because of an outbreak or contact tracing.
  • In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?
    • If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”
  • In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?
    • If you have already gone for a test and got a negative result, select "No."
    • If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."
  • In the last 10 days, have you tested positive on a rapid antigen test or a homebased self-testing kit?
    • If you have since tested negative on a lab-based PCR test, select “No.”
  • In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements) in the last 14 days?
    • If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
  • In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days?
    • If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
  • Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?
    • If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
    • If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”
1. Do any of the people planning to enter the facility answer yes to any of the above questions? *This question is required.
Please do not attend practice. We recommend that you consult your medical physician or contact Telehealth.