Athéna

Infectious symptoms assessment questionnaire
To be completed within 4 hours before coming to your training site FR

*Warning! This form has been modified recently. Please read the questions attentively and answer accordingly.

Are you

First name*

Last name*

Sport*

Role*

Poste*

Phone to contact you*

Email*

Actually residing in*

Next training location attended*

Check the appropriate mention

1. Have you been completely vaccinated against COVID-19 (both doses for more than 14 days)? *

Yes No

a. If so, date of 2nd dose.

b. Date 3rd dose, if applicable

c. Vaccine 3rd dose, if applicable

d. Date 4rd dose, if applicable

e. Vaccine 4rd dose, if applicable

2. Have you received a positive result for covid in the last 2 months?*

Yes No

a. Date of test

b. Please link a photo of your test or proof of your result

3. Have you received a positive result for covid in the last 10 days?*

Yes No

a. Date of test

b. Type of test

Antigenic PCR

c. Please link a photo of your test or proof of your result

4. Do you have any of the following symptoms?*

a. Feeling feverish, shivering like if you had the flu OR a fever measured with a temperature taken by mouth of 38°C or higher.

Yes No

b. Recent cough or cough that has recently worsened

Yes No

c. Sudden lost of smell or taste without nasal congestion

Yes No

d. Shortness of breath or trouble breathing

Yes No

e. Intense and unusual fatigue without obvious reason

Yes No

f. Unusual headache

Yes No

g. Nausea, vomiting or diarrhea in the last 12 hours

Yes No

h. Muscular pain or unusual aches (unrelated to physical effort)

Yes No

5. Have you been in contact with a person who tested positive for Covid in the past 10 days?*

Yes No

a. Date

6. Have you taken an antigenic test today?

Yes No

a. Test results

Pos Neg

b. Photo or proof of your AG test

In accordance with the health rules concerning COVID-19, you may not be authorized to enter your training site.

Any false declaration will result in expulsion from the training site for a period that may last until COVID-19 restrictions are completely lifted. The offending person will be prohibited from accessing the training site and using its facilities and services for the duration of the expulsion period.

In the event that I begin to present one of the above-mentioned symptoms while on the training site, I agree to immediately notify a manager at the site reception and I agree to be isolated in a room until I can call 1-877-644-4545 or leave the site safely.

This questionnaire is confidential. However, I accept that the Institut National du Sport du Québec and managers from the selected training site may communicate certain information collected to the competent authorities, if necessary.

I understand that these measures have been put in place to protect the health and safety of everyone. Zero risk does not exist and there is currently little scientific data on the risk of transmission in very high intensity sports activities involving athletes. Despite the health measures put in place, there remains a risk of contracting COVID-19 while training at the site.

I agree to respect these measures as well as the directives given by the government authority on the matter and I accept the risks presented by visiting

I understand that these measures have been put in place to protect the health and safety of everyone.

I have read the instructions and guidelines for a safe return to work, I understand its contents and agree to comply with it.

I confirm that the provided informatation is accurate.

I UNDERSTAND THAT ANY ERRONEOUS QUESTIONNAIRE, FALSIFIED TEST OR UNACCEPTABLE BEHAVIOUR WILL LEAD TO SANCTIONS BY L'INS QUÉBEC.

Important reminder

Please inform us of all your interprovincial or international travels at least two weeks before your return to the INS Québec Complex. To transmit this information or for any other questions regarding COVID : testcovid@insquebec.org