PHA Covid-19 Self Screening Questionnaire (Pickering Minor Hockey Association)

Print PHA Covid-19 Self Screening Questionnaire
The safety, health and well-being of our PHA participants, members, staff and guests is our top priority. Please complete this questionnaire on the same day you (or the participant) are entering the facility, and be prepared to display your printed submission email to staff at your designated entrance at the facility. If you do not bring a copy to your on-ice session, you may be required to fill out a paper form at the facility or pass a verbal screening at the door. ***Important - Only Ice Participants need to complete the PHA Screening - the City of Pickering will be screening all adults/spectators****
HEALTH QUESTIONNAIRE
Please read the questions below carefully. All questions are mandatory and must be answered to submit this form.






  1. Check All That Apply
  2. Select One
  3. This can be because of an outbreak or contact tracing.
  4. If you have since tested negative on a lab-based PCR test, select "No."
Contact Information
Please fill out all required contact information. This form includes the individual filling out this form, as well as Ice Participants (if you are filling this form out on behalf of your children).
  1. RadDatePicker
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  2. First and Last
  3. First and Last
  4. Example: ###-###-####
  5. Example: [email protected] Your submission will be sent to this address.
  1. By checking here, you are acknowledging that all of the information above is correct; you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to fill out this screening form on paper at the facility. 

    You are acknowledging that this form is used for the purpose of contact tracing and that the PHA or the City of Pickering has the right to contact you in regards to contact tracing due to Covid-19; you consent that if you are experiencing any of the above symptoms, have been instructed to self isolate or are not feeling well that you will refrain from attending PHA activities. 
Human Validation