COVID-19 Screening Questionnaire

Form must be filled out no more than 12 hours before taking to the field.

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LTPD Division – Covid-19 Screening Questionnaire

You are being asked to screen before entering any of the playing fields (even if you have been vaccinated). In Step 2 Maple Leaf Cavan FC is required to actively screen players and fans as per the advice of the Office of the Chief Medical Officer of Health. Read about the public health measures in effect for more details.

The questions in this tool have been defined by the Ministry of Health. Using this specific online tool to answer the questions is optional and is not tracked or enforced. Screening is not required for emergency services or other first responders entering a business or public place for emergency purposes.

This screening cannot diagnose you. If you have medical questions, consult a health care provider. Follow the direction of your local public health unit over the advice in this tool.

Step 1 of 5

20%

Covid-19 Screening

Please read through the questionnaire and answer all of the questions accurately. Players or fans who arrive at the field and appear to be symptomatic will not be allowed to participate. If you not feeling well, or showing any signs of any illness please stay home. If you have any symptoms or answer yes you must stay home for a minimum of 24 hours after the last symptom subsides.

It is critical that no one enter the field if they or someone from their household has symptoms. Please notify your coach if your child is not attending and the reasons for missing, this is for tracking purposes. You will automatically get an email after submitting this form and will show this to the person filling out the tracking sheet for your team.

Please indicate if this screening is for player or non player (parent/guardian, sibling, etc)(Required)

Player

Non Player

Contact Details

Email Address(Required)

Player Name(Required)

First Last

Name(Required)

First Last

Contact Number(Required)

Division(Required)

This questionnaire must be completed by each individual prior to participation in each on field activity.

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

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

If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating.

1. Getting treatment that compromises (weakens) your immune system (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)
2. Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition)
3. Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

Self Assesment

Are you currently experiencing any of these symptoms?

Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Self Assesment

Fever and/or chills
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup)
Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)

Shortness of breath
Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)

Decrease or loss of taste or smell
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Sore throat or difficulty swallowing
Painful swallowing (not related to seasonal allergies, acid reflux, or other known causes or conditions you already have)

Runny or stuffy/congested nose
Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have

Headache
Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, tension-type headaches, chronic migraines, or other known causes or conditions you already have)

Digestive issues like nausea/vomiting, diarrhea, stomach pain
Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have

Extreme tiredness or muscle aches
Unusual, fatigue, lack of energy, poor feeding in infants (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, sudden injury, or other known causes or conditions you already have)

Self Assesment(Required)

None of the Above

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?(Required)

If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.”

If the person got a COVID-19 vaccine in the last 48 hours and is experiencing a mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”

Yes

In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?(Required)

Yes

In the last 14 days, have you been identified as a “close contact” of someone who currently has COVID-19?(Required)

If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series) and have not been told to self-isolate by public health, select “No.”

Yes

In the last 14 days, has anyone you live with:(Required)

Travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)? or been identified as a “close contact” of someone who currently has COVID-19 and been told to self-isolate by a doctor, healthcare provider, or public health unit? If you are fully vaccinated, select “No.”

Yes

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?(Required)

This can be because of an outbreak or contact tracing.

Yes

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?(Required)

If you have since tested negative on a lab-based PCR test, select "No."

Yes

In the last 14 days, have you received a COVID Alert exposure notification on your cell phone?(Required)

If you are fully vaccinated (it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series), select “No.”

If you already went for a test and got a negative result, select “No.”

Yes

DO NOT go to the field on 04/18/2024

Based on your answers, you either have symptoms or may have been exposed to COVID-19.

We recommend that you stay home to protect the health and safety of others. You could be carrying and spreading the virus without knowing it.

If anyone has symptoms or is waiting for test results

Everyone in your household who is not fully vaccinated must stay home if anyone has COVID-19 symptoms or is waiting for test results after experiencing symptoms. Stay home until the person with symptoms gets a negative COVID-19 test result, or is cleared by public health, or is diagnosed with another illness.

Phone

This field is for validation purposes and should be left unchanged.

Contact Us

P.O. Box 274
Millbrook, ON, L0A 1G0
info@cavanfc.com

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