Troop 212 / COVID-19 Questionnaire

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Form is ONLY valid, if completed on the SAME day as the event. Do not fill out the form before the day of.

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Participant Name (first and last) *

Contact Phone (xxx-xxx-xxxx) *

Contact E-Mali *

Event Name

In the last 48 hours, have you experienced any of the following symptoms? (Please check “yes” or “no.”) If “yes” is answered to any question the respondent may not attend the event. *

Yes

Body temperature 100F or greater

Chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Within the last 10 days have you had a COVID test and not received results?

Do you live in the same household with, or have had close contact with someone who within the past 14 days has (1) been in isolation for COVID-19; or (2) tested positive for COVID-19?

Yes