TCYOLI Wellness Screening Form

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Email *

Today’s Date: *

YYYY

Team: *

Blue team

White team

Woodwind

Parent/Staff

Name: *

1. Do you have a fever of 100 and above or have felt hot or feverish recently (14-21 days)? *

Yes

2. Do you exhibit shortness of breath or other difficulties breathing? *

Yes

3. Do you have a cough? *

Yes

4. Do you have any other flu-like symptoms, such as gastrointestinal issues, headache or fatigue? *

Yes

5. Have you experienced recent loss of taste or smell? *

Yes

6. Have you been in contact with any confirmed Covid-19 positive patients? *

Yes

7. Have you recently traveled to a restricted State that is under New York State Travel Advisory according to Governor Cuomo’s Executive Order 205? *

Yes

Positive responses to any of these would likely indicate a deeper discussion with any TCYOLI admin team member before coming to the weekly rehearsal. Any other comments?

A copy of your responses will be emailed to the address you provided.

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