Skip survey header

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 COVID-19 screening tool for schools and child care settings - Version 4.6 – March 21, 2022

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:

When the option of [5, 10] days is listed:
  • Use 5 days if you are fully vaccinated AND/OR 11 years old or younger
  • Use 10 days if you are 12 years old or older and not fully vaccinated OR if you are immunocompromised, OR if you attend or work at a school or student lodging in a highest risk congregate care setting (e.g. a hospital school, or an Education and Community Partnership Program).

Questions:

1. In the last [5, 10] days have you experienced any of these symptoms?
 
Anyone who is sick or has any new or worsening symptoms of illness, including those not listed below, should stay home until their symptoms are improving for 24 hours (or 48 hours for nausea, vomiting, and/or diarrhea) and should seek assessment from their health care provider if needed.

You may select “No” to all symptoms if all of these apply:
  • You have completed your isolation of [5/10] days OR you tested negative for COVID-19 on one PCR test or rapid molecular test, or two rapid antigen tests taken 24 to 48 hours apart AND
  • You do not have a fever AND
  • Your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea).
Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
  • Fever and/or chills (Yes/No)
    • Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher and/or chills
  • Cough or barking cough (croup) (Yes/No)
    • Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, or other known causes or conditions they already have)
  • Shortness of breath (Yes/No)
    • Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions they already have)
  • Decrease or loss of taste or smell (Yes/No)
    • Not related to seasonal allergies, neurological disorders, or other known causes or conditions they already have
2. In the last [5, 10] days have you experienced any of these symptoms?

If you only had one of these symptoms, you may select “No” if your symptom has been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea).

If you had two or more of these symptoms, you may select “No” if all of these apply:
  • You have completed your isolation of [5/10] days OR you tested negative for COVID-19 on one PCR test or rapid molecular test, or two rapid antigen tests taken 24 to 48 hours apart AND
  • You do not have a fever AND
  • Your symptoms have been improving for 24 hours (48 hours if you have nausea, vomiting, and/or diarrhea).
  •  
Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
  • Sore throat or difficulty swallowing (Yes/No)
    • Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)
  • Runny or stuffy/congested nose (Yes/No)
    • Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have
  • Headache (Yes/No)
    • Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)
    • If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing a mild headache that only began after vaccination, select “No.”
  • Extreme tiredness (Yes/No)
    • Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid disfunction, sudden injury, or other known causes or conditions you already have)
    • If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild fatigue that only began after vaccination, select “No.” 
  • Muscle aches or joint pain (Yes/No)
    • If you received a COVID-19 and/or flu vaccination in the last 48 hours and are experiencing mild muscle aches/joint pain that only began after vaccination, select “No.”
  • Nausea, vomiting and/or diarrhea (Yes/No)
    • Not related to irritable bowel syndrome, anxiety, menstrual cramps, or other known causes or conditions they already have
3. In the last [5, 10] days have you tested positive for COVID-19? (Yes/No)

This includes a positive COVID-19 test result on a lab-based PCR test, rapid molecular test, rapid antigen test or home-based self-testing kit.

Select “No” if you have already completed your isolation period of [5, 10] days because your symptoms started before your positive test result AND:
  • your symptoms have been improving for 24 hours (48 for nausea, vomiting, and/or diarrhea) AND
  • you do not have a fever

4. Do any of the following apply? (Yes/No)
 
  • You live with someone who is currently isolating because of a positive COVID-19 test
  • You live with someone who is currently isolating because of COVID-19 symptoms (any one or more symptoms from question 1 above or any two or more symptoms from question 2 above)
  • You live with someone who is isolating while waiting for COVID-19 test results
Select “No” if you:
 
  • are 18 years of age or older and have received your booster OR
  • are 17 years of age or younger and are fully vaccinated OR
  • completed your isolation after testing positive in the last 90 days (using a rapid antigen, rapid molecular, or PCR test).
Select “No” if your household member is isolating because of COVID-19 symptoms but has already tested negative on one PCR or rapid molecular test, or two rapid antigen tests.

5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? (Yes/No)

This can be because of an outbreak or contact tracing.

6. Do any of the following apply? (Yes/No)
  • In the last 14 days, you travelled outside of Canada and were told to quarantine.
  • In the last 14 days, you travelled outside of Canada and were told to not attend school/child care.
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.