Hybrid 17 Medical History Form

Hybrid 17 Medical History Form - CONFIDENTIAL

Please complete before arriving to camp
Your Full Name*
Today's Date*

MonthDayYear
Date
What crew are you on?*
The information provided below is for use in safety planning and emergencies. The purpose is to plan for a safe season (eg if you have bee sting allergies, do you have an Ana-kit?) and to alert first aiders and health care professionals of any medical condition or allergy you have in the event that you cannot speak for yourself. Please fill out the form completely and accurately. THIS INFORMATION WILL BE SHARED WITH OWNERS AND SUPERVISORS AND, IF NECESSARY FOR SAFETY, RELEVANT FIRST AIDERS. THE INFORMATION WILL BE TREATED WITH DISCRETION AND CONFIDENTIALITY. YOU MAY BE CONTACTED BY PHONE WITH THE INTENTION OF SUPPORTING YOU TO HAVE A GOOD SEASON AHEAD.
Your Home Address (in full)*
Please include town, prov, postal code
Email*
example@example.com
Your Phone Number*
Your Date of Birth*

MonthDayYear
Date
Medical Insurance/Card Number*
Province of medical coverage*
SIN*
Emergency Contact Person*
Emergency Contact Phone Number*
Relationship to You*
COVID-19 Vaccination Status*
We are asking this question, as employers ARE REQUIRED to report on what percent of their workers are vaccinated so that local health authorities can ensure they have adequate capacity in the case of an outbreak. For a small northern town, a large camp with even a quarter of people sick can really bog down their little clinic. However, this does NOT include sharing of ANY personal information, and the only thing employers will be doing is sharing a numerical breakdown of their workers (i.e. 80% vacc, 10% partly vacc, 10% unvacc or undeclared). You can decline to answer but will be considered unvaccinated if you do. Unvaccinated workers who contract COVID may be subject to a longer isolation period (10 days) than vaccinated workers (5 days) and may also be required to isolate if they are in close contact with other known cases (i.e. in a truck with them).
Medical Conditions/Diagnoses/Surgeries (epilepsy, diabetes, etc)
Mental Health and Addictions History (depression, anxiety, bipolar, alcohol/drug use, etc.)
Allergies (bee stings, penicillin, food allergies etc) / Reaction type (anaphylaxis, hives, loose stools, etc)
Prescription Medications (Ana kit, insulin, antidepressants etc)
Specialists Involved in your Care (eg endocrinologist, psychiatrist, orthopedic surgeon, etc.)
Other (anything else you think a doctor should know about you)
Should be Empty:

Hybrid 17 Medical History Form - CONFIDENTIAL