REFEREE OHF Screener/ Contact Tracing Form (Milton Minor Hockey)

Print REFEREE OHF Screener/ Contact Tracing Form
  1. Terms and Conditions:

    I acknowledge that I will submit this screener on the day of each scheduled shift, prior to arriving at the arena.  I acknowledge that failure to do so may compromise my shifts in future.  

    I acknowledge that if anyone in your household has Covid-19 symptoms, is waiting for Covid-19 testing results,has tested positive for Covid-19, or been in close contact with anyone with Covid-19 symptoms, or tested positive for Covid-19, no one in your household is permitted to attend any hockey related activities on or off the ice. 

    I will also notify 
    the MMHA communications officer at and  I will not attend a referee shift until permitted as per Halton Public Health. 

    The player’s/coach’s return will be coordinated with our Communication Director Malcolm Kelly and Halton Public Health.
Session Info
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  2. Ex 12-4 pm
Referee Info
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  2. Example:
  3. Example: ###-###-####
  1. Terms and Conditions: Are you currently experiencing any of these issues? Call 911 if you are. You cannot participate in on-ice or off-ice activities. 


    1 Severe difficulty breathing (struggling for each breath, can only speak in single words)


    2 Severe chest pain (constant tightness or crushing sensation)


    3 Feeling confused or unsure of where you are


    4 Losing consciousness

  2. Terms and Conditions: If you are in any of the following at risk groups, we ask that you speak with your physician prior to participating:

    170 years old or older.
    2Gettintreatment  thacompromises  (weakensyouimmunsystem (for example, chemotherapy, medication for transplants, corticosteroids, TNF inhibitors)

          3Having a condition that compromises (weakens) your immune system (for example, diabetes, emphysema, asthma, heart condition)
    4 Regularly going to a hospital or health care setting for a treatment (for example, dialysis, surgery, cancer treatment)

  3. Terms and Conditions: The answer to all questions must be “No in order to participate in any and all activity (on-ice or off-ice).

    1. Are you currently experiencing any of these symptoms?

    *Do you have a Fever? (Feeling hot to touch, temperature of 37.8C or higher) 
    *Cough that's new or worsening (continuous.more than usual)
    *Barking cough, making a whistle noise when breathing (croup) 
    *Shortness of breath (out of breath, unable to breathe deepley) 
    *Sore throat
    *Difficulty swallowing
    *Runny nose, sneezing, or nasal congestion (not related to seasonal allergies or other known causes or conditions) 
    *Lost sense of smell or taste
    *Pink Eye (conjunctivitis) 
    *Headache that's unusual or long lasting
    *Digestive Issues (nausea/vomiting, diarrhea, stomach pain) 
    *Muscle aches 
    *Extreme tiredness that is unusual (fatigue, lack of energy) 
    *Falling Down often
    *For young children and infants: sluggishness or lack of appetite

  4. Terms and Conditions: The answer  to alquestions must be “No in order  to participate in anyon ice activity.

    r the remaining questions, close physical contact means being less than 2 metres away in the same room, workspace, or area for over 15 minutes or living in the same home

    *In the last 14 days, have you been in close physical contact with someone who tested positive for COVID-19?

    *In the last 14 days, have you been in close physical contact with a person who either:

    *Is currently sick with a new cough, fever, or difficulty breathing;
    OR Returned from outside of Canada in the last 2 weeks?

    *Have you travelled outside of Canada in the last 14 days?


  5. Terms and Conditions: If a referee answered Yes” to any of these questions, they are not permitted to participate in anon-ice activities.

Human Validation
Printed from on Friday, November 27, 2020 at 9:17 PM