COVID Health Screening Questionnaire
Sign in to Google to save your progress. Learn more
Email *
Within the last 10 days have you or those swimming been diagnosed with COVID-19 or had a test confirming you or those swimming have the virus? *
Do you or those swimming live in the same household with, or have you had close contact* with someone in the past 14 days  who has been in isolation for COVID-19 or had a test confirming they have the virus? (*NOTE: ʺClose Contactʺ is defined as living in the same house, being an intimate partner, being a caregiver, or being within 6 feet of an individual for longer than 15 minutes who has COVID-19) *
Required
Have you or those swimming had a fever of 100 Fahrenheit (37.8 Celsius) or higher in the past 14 days? *
Required
Have you or those swimming had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by a reason other than possibly having COVID-19? COVID related symptoms include: Fever, cough, sore throat, shortness of breath/difficulty breathing, feeling unusually weak/fatigued, loss of taste/smell, muscle pain, headache, runny/congested nose, diarrhea, nausea and vomiting. *
Required
By electronically signing below, and to the best of your knowledge, I attest that the answers I have indicated above are true.  To electronically sign, type your name below. *
Key # *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms