Active Screening Questionnaire
for Adults in Recreation Programs
Active Screening is a review of your health. Completing Active Screening BEFORE each participation in a recreational program is a mandate of the Ministry of Health and Ottawa Public Health. Submitting this Questionnaire electronically to the Manor Park Community Council (MPCC) makes it easy for you to comply.
It helps everyone remain safe and healthy!
Information collected will be used by the Manor Park Community Council for the administration and management of arts, sports, and fitness programs. Information will only be shared as legally required.
Screening Questions (all questions must be answered)
1. Do you have one or more of the following symptoms?
YES NO
Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.
Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher
Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)
Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)
Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have
Unusual, long-lasting (not related to getting a COVID-19 vaccine in the last 48 hours, a sudden injury, fibromyalgia, or other known causes or conditions you already have)
Unusual, fatigue, lack of energy (not related to getting a COVID-19 vaccine in the last 48 hours, depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)
2. In the last 14 days, have you travelled outside of Canada and been told to quarantine (per the federal quarantine requirements)?
YES NO
3. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?
YES NO
This can be because of an outbreak or contact tracing.
4. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?
YES NO
If you have since tested negative on a lab-based PCR test, select "No."
Results of Screening Questions
If you answered “YES” to any of these question you may not attend the program today.
Please contact Ottawa Public Health at (613)580-6744 for guidance.
If you answered “NO” to all questions, you may attend the program today.
By signing below, you are confirming you have answered NO to all questions and you are cleared to attend the program.
Please accept all conditions.