1. SVC Daily COVID-19 Questionnaire (Stratford Volleyball Club)

Print 1. SVC Daily COVID-19 Questionnaire

The SVC Health Screening Questionnaire must be completed each day before you will be permitted to enter the Agriplex or training area, all of the following questions must be answered. If the answer to any question is yes, then entry is not permitted.

Player/Coach/Volenteer Information

First Name ^*
Last Name:^*
Team ^*

SVC Health Screening Questionnaire

Please answer the 4 questions below before each visit to the Agriplex.

Do you have any of the following symptoms: fever/feverish, new or worsening cough, difficulty breathing, runny nose or nasal congestion not related to allergies, sore throat, recent loss of taste or smell, pink eye, unusual headache, diarrhea, unexplained muscle aches, unexplained fatigue?^*
YesNo
Have you traveled internationally (outside of Canada) within the last 14 days?^*
Yes No
Have you had close contact with a confirmed or probable COVID-19 case in the last 14 days?^*
YesNo
Have you had close contact with a person with acute respiratory illness who has been outside Canada in the last 14 days? Note: close contact means living in the same home, working in the same room, being less than 2 meters away in the same room.^*
YesNo

If you have answered NO to all 4 questions you are permitted to enter the Agriplex at your scheduled time.

If you have answered YES to any of the 4 questions, you are not permitted to enter the Ariplex and you should contact your health care provider or be assessed at the Stratford COVID-19 assessment centre (519-272-8210 Ext. 2747) to get tested and/or further direction.

Human Validation

Check The Box ^*

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Thu Jan 21, 2021

Printed from stratfordvolleyballclub.com on Thursday, January 21, 2021 at 12:18 AM