Hockey North COVID-19 Screening and Contact Tracing Form

This screening form must be completed by every participant (player, coach) prior to every Hockey North sanctioned activity. Please answer every question to assist with contact tracing should there ever be a need.

Participant First name

Participant Last Name

Contact Number

Contact e-mail

Territory

Community / Facility (Yellowknife / Arena, Ed Jeske or Shorty Brown)

What age division are you taking part in?

What time does your ice session start?

Are you experiencing any of the following symptoms:

Have you been outside of Canada within the last 14 days?

Have you returned to either Northwest Territories or Nunavut from other parts of Canada within the last 14 days?

In the last 14 days, have you been in close contact with someone who:

Hockey North COVID-19 Screening and Contact Tracing Form

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