Football - Mt. Horeb High School Daily Health Self Checklist

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Please complete the Daily Health Self Checklist form EACH Day & submit between 2:00-3:25pm on EVERY day of practice or game/meet/match. If you do not complete this form daily by 3:25pm, you will not be able to attend practice or the event for that date.

You should stay home if symptoms are present. If an athlete becomes ill during practice or an event, he/she will be removed & sent home.

Email *

Athlete First Name *

Athlete Last Name *

Sport *

Football

Do you have any of the following symptoms? Please check all that are present & record your temperature *

No Symptoms

Cough

Shortness of breath or difficulty breathing

Chills or Repeated shaking with chills

Muscle pain

Headache

Sore throat

New loss of taste or smell

Other - if you select this, someone from the Athletics Office will be contacting you

Required

Fever >= than 100.4 degrees (enter temperature below) *

Would you like for Nurse Goodwin to contact you for any reason or to discuss any questions or concerns you may have health wise? *

Yes

REMINDER on possible Covid-19 Exposure You MUST notify your Head Coach & school nurse, CJ Goodwin (goodwincheyenne@mhasd.k12.wi.us). Students must report immediately!

1. If they are diagnosed with COVID-19 by a positive lab test or a diagnosis from a health care provider without lab testing;

2. If they are exhibiting symptoms of COVID-19 and are awaiting diagnosis;

3. If they are living with a person that has been diagnosed with COVID 19; or

4. If they had close contact with a person that has been diagnosed with COVID-19.

If a student has one of the following symptoms of illness the student needs to be out for 24 hours and can return once symptoms subside: diarrhea and vomiting.

Any ONE of the following symptoms require a 10 day isolation, negative COVID-19 test or a physician's note of alternate diagnosis in order to return: Fever, Cough, shortness of breath or difficulty breathing.

Any TWO of the following symptoms require 10 day isolation, negative COVID-19 test or a physician's note of alternate diagnosis in order to return: Sore throat, runny nose/congestion, new lack of taste or smell, muscle pain/shivers, headache, nausea/vomiting, diarrhea and fatigue.

Send me a copy of my responses.

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