Required fields are marked with asterisks (*)

COTB Youth Programs COVID-19 Screening Tool

Note: This tool must be filled out on the day of your programming.

Please complete all questions and submit your results. Once submitted, if you provide an email address, an email will be sent. Otherwise, you will need to show an image or the page. Proof of completing this tool must be shown prior to entering the recreation facility. Thank you for your co-operation.

** Fully vaccinated means - it has been 14 or more days since your final dose of either a two-dose or a one-dose vaccine series **

If you are a parent or guardian answering on behalf of the Participant, please answer as it relates to THEM.

Do you or anyone in your household have any new or worsening COVID-19 symptoms?
Symptoms should not be chronic or related to other known causes or conditions.

  • Fever and/or chills (a temperature of 37.8 C/100 F or greater)
  • Cough or barking cough (croup, continuous, more than usual, making a whistling noise)
  • Shortness of breath (out of breath, unable to breath deeply)
  • Decrease or loss of smell or taste


Two or More of:

  • Sore Throat
  • Runny or stuffy/congested nose
  • Headache
  • Extreme tiredness
  • Muscle aches or joint pain
  • Gastrointestinal symptoms (such as nausea or diarrhea)

* If you or anyone you live with have symptoms, you and anyone you live with must isolate for five days if you are fully vaccinated and otherwise healthy.
* If you are not fully vaccinated or are immunocompromised, you and anyone you live with must isolate for 10 days.

Have you travelled outside of Canada in the last 14 days AND been advised to quarantine per the federal quarantine requirements?

In the last 10 days, have you been exposed to a COVID-19 positive person or someone who currently has symptoms of COVID-19?

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 vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared) select “No”.

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 tested positive on a rapid antigen test or a home based self-testing kit?
If you have since tested negative on a lab-based PCR test, select “No”.

Acknowledgements

I understand that if I do not pass this screening tool I am not to enter the program.

If you think you may have COVID-19 or were exposed to the virus, please visit the Ontario COVID-19 website to take care of yourself and protect others.

Any collection of personal information is made under the authority of the Ministry of Health COVID-19 Guidance for facilities for sports and recreational fitness activities during COVID-19. Personal information is collected in compliance with the Municipal Freedom of Information and Protection of Privacy Act.

Personal information is collected for the purpose of complying with provincial orders related to the COVID-19 pandemic.  None of your personal information will be shared, rented, sold or otherwise released to any third party without your consent. 

Any questions about this collection should be directed to: 625-2351.



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