Orono Arena Health Screening Form - 2021-22 Season (Orono Amateur Athletic Association)

Print Orono Arena Health Screening Form - 2021-22 Season

This form must be filled out prior to entry to the Orono Arena. The form must be filled out by each person, everytime.

Arena Patron Information

Name of Person Entering Arena^*
Child (Player) Name

If Applicable
Organization^*
If you chose 'Other' above, please state Organization

Date of Visit^*

Open the calendar popup.

Time of Visit^*

Open the time view popup.

Email Address

Example: [email protected]
Contact Phone Number^*

Example: ###-###-####
Player's Team (if applicable)
Player Jersey Number (if applicable)

Health Screening

Are you or anyone in your group currently experiencing any one of the following symptoms that are new or worsening? Fever or chills, cough or barking cough, shortness of breath, decrease or loss of smell or taste or fatigue?^*
YesNo
Is anyone you or a member of your group live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?^*
YesNo
If yes, you and the rest of your household will need to stay at home until the sick individual gets a negative COVID-19 test result, is cleared by their local public health unit, or is diagnosed with another illness.
Has a doctor, health care provider, or public health unit told you or your group that you or a member or your group should currently be isolating (staying at home)?^*
YesNo
This can be because of an outbreak or contact tracing
In the last 10 days, have you or a member of your group been identified as a "close contact" of someone who currently has COVID-19?^*
YesNo
In the last 10 days, have you or your group received a COVID Alert exposure notification on your cell phone?^*
YesNo
If you or your group have already gone for a test and got a negative result, select "No".
In the last 14 days, have you or your group travelled outside of Canada AND been advised to quarantine per the federal quarantine requirements?^*
YesNo
In the last 10 days, have you or your group tested positive on a rapid antigen test or a home based self-testing kit?^*
YesNo
If you have since tested negative on a lab based PCR test, select "No"

PLEASE NOTE: This Health Screening questionnaire has been developed based on the current Ontario Ministry of Heath Self Assessment Tool. *For information on Travel Exemptions to the emergency order of the Government of Canada's Quarantine Act, please go to http://canada.ca/en/publichealth/services/diseases/2019-novel coronavirus-infection/latest-travel-health-advice.html#a3

Human Validation