A's Rep > Covid-19 Self Assessment Form (Oakville Minor Baseball)

Print Covid-19 Self Assessment Form

Participant's Information

First Name^*
Last Name^*
Email Address (Parent/Guardian if under 18)^*

Example: [email protected] Your submission will be sent to this address.

Event

Date and Time of Game/Practice/Event^*

Self Assessment to be completed WITHIN 12 HOURS of game/practice

Do you have a fever?^*
YesNo
Do you have a cough?^*
YesNo
Do you have difficulty breathing?^*
YesNo
Do you have a sore throat, trouble swallowing?^*
YesNo
Do you have a runny nose?^*
YesNo
Do you have loss of taste or smell?^*
YesNo
Do you have nauseau, vomiting, diarrhea?^*
YesNo
Have you been in close contact with someone who has confirmed or probable Covid-19 in the past 14 days without wearing appropriate PPE?^*
YesNo
Have you returned from travel outside Canada in the past 14 days?^*
YesNo

If you answered YES to any of these questions, do NOT attend the game/practice. Self isolate right away. Call Telehealth or your health care provider, to find out if you need a test

Human Validation

Covid-19 Self Assessment Form, A's Rep (Oakville Minor Baseball)