Covid-19 Screening (Burford Minor Hockey)

Print Covid-19 Screening

Please Pre Screen before arriving to participate. This also helps the County of Brant and Brant County Health Unit comply with the provincial Response Plan by knowing who has visited the building.

Contact

Please Provide Contact Info.

Reason for Visit^*
PlayerCoachSpectatorRefereeTime Keeper
Name of Participant^*
Name Parent Guardian Contact
Home Team
Contact Phone#^*

Example: ###-###-####
Visiting Team Name

Only fill in if you are the visiting team.

Location

Date of Event^*

Open the calendar popup.

Time of Event^*

Open the time view popup.

Location ^*

Assesment

Do you have a fever greater than or equal to 38°C (100.4°F) and/or a new onset of cough or difficulty breathing?
YesNo
Have you returned from travel outside of Canada in the past 14 days?
YesNo
Have you been asked to self-isolate?
YesNo
Have you been in close contact with or had unprotected exposure to a confirmed or probable case of COVID-19?
YesNo
Have you had close contact with or had unprotected exposure to any person with an acute respiratory illness who has returned from travel outside of Canada with the past 14 days prior to their illness onset
YesNo
Do you have flu like symptoms, runny nose, cough, sore throat, diarrhea?
YesNo