COVID-19 Incident Reporting

OMHA Association COVID-19 Incident Reporting
BEFORE PROCEEDING PLEASE READ AND ACKNOWLEDGE BELOW THE FOLLOWING:

If a sick participant (or their parent/guardian if the participant is a minor) elects to inform a team/hockey association/Member that they have been diagnosed with COVID-19, the individual informed shall seek the sick participant/their parent’s/guardian’s consent to contact public health authorities in order to obtain advice on communication with other potentially impacted participants. The sick participant (or their parent/guardian if the participant is a minor) should be asked to advise Public Health of this consent. Explain the communication that will take place and NEVER disclose the sick person’s name.

When completing this Incident Report specifics regarding the individual(s) involved are NOT to be reported for privacy reasons. The only information required will be to verify that reporting protocols have been followed and that any direction received from PHU(s) has been completed.

COMPLETE THIS FORM ONLY IF DELIVERY OF YOUR PROGRAMMING, IN PART OR FULL, HAS BEEN IMPACTED
I acknowledge that I have read the information above and our Association is in compliance with this directive: *

Yes No
Name of Association *
Association COVID-19 Communications Officer: *

First Name Last Name
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Date Incident of COVID-19 was reported to your Association *

Month Day Year
Date
Does this event involve an on-ice/off-ice official (referee, linesman or scorekeeper) *

Yes No
What age group(s) have been impacted? *

U5 (Preschool) U7 U8 U9 U10 U11 U12 U13 U14 U15 U16 U17 U18 U21
Has your Association received permission from the parent/guardian of the sick participant, or the on/off ice-official, to report this incident to the applicable Public Heath Unit(s)? *

Yes No
Has your Association reported this incident to the applicable Public Heath Unit(s)? *

Yes No
Please select the name of the Public Health Unit(s) involved:

Chatham-Kent Health Unit Durham Region Health Unit GreyBruce Health Unit Haldiman-Norfolk Health Unit Haliburton, Kawartha, Pine Ridge District Health Unit Halton Region Health Department Hamilton Public Health Services Hastings and Prince Edward Counties Health Unit Huron Perth Health Unit Kingston, Frontenac and Lenox & Addington Health Unit Lambton Health Unit Leeds, Grenville and Lanark Distirct Health Unit Middlesex-London Health Unit Niagara Region Public Health Department North Bay, Parry Sound District Health Unit Peel Public Health Peterborough Public Health Region of Waterloo Simcoe, Muskoka District Health Unit Southwestern Public Health Wellington-Dufferin-Guelph Health Unit Windsor-Essex County Health Unit York Region Public Health Services Other
Please describe the direction provided by the PHU(s):
Has the direction of the PHU(s) been implemented?

Yes No
If consent to contact the PHU(s) was not received from the parent/guardian of the sick participant, or the on/off ice-official, what action has been taken by your Association?
If programming for this age group has been suspended, what is the expected date of return?

Month Day Year
Date
Please upload any additional documentation that you may have that is relevant to this incident.

Cancel of
Should be Empty:

OMHA Association COVID-19 Incident Reporting