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
An employee
A visitor
First name*
Last name*
Sport*
Alpine skiing
Alpine skiing-para
Archery
Archery-para
Artistic swimming
Athletics
Athletics-para
Badminton
Baseball
Basketball
Basketball-para
Beach Volleyball
Biathlon
Bobsleigh
Boccia
Boxing
Canoe-kayak - para
Canoe-kayak - Slalom
Canoe-kayak - Sprint
Climbing
Cross-country skiing
Cross-country skiing-para
Curling
Curling-para
Cycling - Mountain bike
Cycling - Road
Cycling - Track
Cycling- BMX
Cycling-para
Diving
Equestrian sports
Equestrian sports - para
Fencing CAN
Fencing QC
Fencing-para
Field Hockey
Figure skating
Football
Freestyle skiing aerials
Freestyle skiing moguls
Freestyle skiing slopestyle
Goalball
Golf
Gymnastics - Artistic CAN
Gymnastics - Artistic QC
Gymnastics - Rhytmic CAN
Gymnastics - Rhytmic QC
Gymnastics - Trampoline CAN
Gymnastics - Trampoline QC
Handball
Hockey-Para
Ice Hockey
INS
Judo
Judo-para
Karate
Luge
Other
Para-Badminton
Pentathlon
Racquetball
Ringette
Rowing
Rowing-para
Rugby 15
Rugby 7
Rugby-para
Sailing
Sailing-para
Shooting
Shooting-para
Skateboard
Skeleton
Ski cross
Snowboard
Snowboard-para
Soccer
Soccer-para
Softball
Speed skating LT
Speed skating ST
Squash
Swimming
Swimming-para
Synchronized Skating
Table tennis
Table tennis-para
Taekwondo
Taekwondo-para
Ten Pin
Tennis
Tennis-para
Triathlon
Triathlon-para
Volleyball
Volleyball-para
Water polo
Weightlifting
Wrestling
Role*
Athlete
Specialist
Coach
Training partner
INS Employee
Supplier
Client
Companion
Visitor
Sport employee
Intern
Poste*
Phone to contact you*
Email*
Actually residing in*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Outside of Canada
Prince Edward Island
Quebec
Saskatchewan
Yukon
Next training location attended*
Académie Performance Isatis
Actiforme - St-Jean-sur-Richelieu
Aréna de Blainville - Patinage synchronisé
Aréna de Boisbriand
Aréna de Boisbriand - Patinage synchronisé
Aréna Howie-Morenz - Hockey
Aréna Howie-Morenz - Patinage artistique
Aréna Martin-Brodeur - patinage artistique
Aréna Maurice Richard - patinage artistique
Aréna Maurice Richard - patinage de vitesse
Aréna Roberto-Luongo - patinage artistique
Aréna Rosemère
Aréna Saint-Eustache
Aréna Ste-Julie
Association Aquatique Dollard-Des-Ormeaux - Natation artistique
Association Aquatique Dollard-Des-Ormeaux - Waterpolo
Athletica Lac Brome
Auditorium de Verdun - Hockey féminin
Auditorium de Verdun - Patinage artistique
Beaudoin Karaté Gatineau
Centre aquatique de Boucherville
Centre aquatique de Pointe-Claire
Centre Bruno-Verret - Lévis
Centre Claude-Robillard - Boxe
Centre Claude-Robillard - Gym ESIM
Centre Claude-Robillard - Gymnastique
Centre Claude-Robillard - Natation
Centre Claude-Robillard - Piste d’athlétisme
Centre Claude-Robillard - Plongeon
Centre Claude-Robillard - Tir à l’arc
Centre Claude-Robillard - Waterpolo
Centre de ski de fond Mont St-Anne
Centre des glaces - anneau Gaëtan Boucher
Centre des glaces Gilles-Chabot - Hockey
Centre des glaces Gilles-Chabot - Patinage artistique
Centre d’arts martiaux Dojo K - Terrebonne
Centre multisport de Châteauguay - Patinage artistique
Centre Multisport Vaudreuil-Dorion
Centre Roland-Dusseault
Centre sportif de Gatineau - Piscine
Centre sportif de Gatineau - Salle PP
Centre Sportif du Cegep Édouard-Montpetit
Centre Sportif Gaëtan Boucher
Centre sportif Université de Sherbrooke
CEPSUM - Hockey
Club de judo Kiseki
Club de Racquetball Edouard Boyer
Complexe de l’INS Québec
Complexe Gadbois
Complexe Marie-Victorin
Complexe sportif St-Constant - Patinage artistique
Complexe Thibault GM - Sherbrooke
Concept Action - Bromont
CÉGEP de Sherbrooke
Diving World Cup
Entourage Sur-le-Lac
Europe Water-Polo Masculin
Excel Gym
Gym Le Garage - Gaspé
IRS - St-Jérôme
La Taule - Waterloo
Parc Jean-Drapeau
Peps Université Laval
Place Bell - patinage artistique
Pro Gym - Boxe
Sani Sport inc. Brossard
SPORTPLEXE Energie - Para hockey
SPORTPLEXE Energie - Patinage artistique
Sportplexe Pierrefonds - Patinage synchronisé
YMHA - Lutte olympique
École secondaire du Séminaire - Sherbrooke
École St-Donat - Maria
Élite Factor - ESQL
Visit reason(s)*
CCES
Formation
Maintenance / Upkeep
Medical clinic
Meeting
Nutrition
Physical preparation room
Training grounds
Work
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 3
rd
dose, if applicable
c. Vaccine 3
rd
dose, if applicable
Pfizer
Moderna
Astra Zeneca
Johnson & Johnson
d. Date 4
rd
dose, if applicable
e. Vaccine 4
rd
dose, if applicable
Pfizer
Moderna
Astra Zeneca
Johnson & Johnson
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