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CYLAX Daily Attestation
This COVID-19 screening must be completed for every practice and game your child attends on the day of.
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Child's Name (First and Last)
*
Your answer
Has your child had any of the following symptoms in the past 3 days that are not explained by allergies or a non-infectious cause?
*
Yes
No
Cough
Shortness of breath or difficulty breathing
Fever or chills
Muscle or body aches
Sore throat
Headache
Nausea or vomitting
Diarrhea
Runny nose or stuffy nose
Fatigue
Recent loss of smell or taste
Yes
No
Cough
Shortness of breath or difficulty breathing
Fever or chills
Muscle or body aches
Sore throat
Headache
Nausea or vomitting
Diarrhea
Runny nose or stuffy nose
Fatigue
Recent loss of smell or taste
Has your child been in close contact (less than 6 feet) with anyone with COVID-19 or COVID-19 symptoms in the past 14 days?
*
Yes
No
Has your child traveled anywhere outside of the 50 United States in the past 14 days?
*
Yes
No
Has your child traveled to a location with a high community spread rate? (see list maintained by RIDOH at
www.health.ri.gov/covid
)
*
Yes
No
Has your child been asked to quarantine or isolate by the RI Department of Health or a health care provider in the past 14 days?
*
Yes
No
Name of Person Completing the Form
*
Your answer
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