LHS Rambler Band Infectious Disease Prevention Health Questionnaire

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Every band member, staff, and volunteer must complete a WCS Infectious Disease Prevention Health Questionnaire before each practice. There is both this digital version and a paper version that band directors will have on hand at all practices. DISCLAIMER: If you answered YES to any question 2-9, we ask that you refrain from entering the building/classroom/practice area at this time.

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Practice Date *

YYYY

Last Name *

First Name *

Person Completing Form *

Student for him/herself

Parent/Guardian for student

Volunteer for self

Band Director for self

Answer the questions as either yes or no. *

Yes

1. Are you feeling healthy and well today?

2. Are you currently taking an antibiotic?

3. Are you currently taking any other medication for an infection?

4. Do you have any respiratory symptoms today? (e.g., sneezing, coughing, runny nose, sore throat, etc.; THIS INCLUDES ALLERGY SYMPTOMS)

5. Have you had a headache or a fever in the last 48 hours?

6. Do you have muscle aches or body aches today?

7. Have you been in contact with anyone displaying ANY of the above symptoms in the past 14 days?

8. Have you traveled outside the country in past 30 days?

9. Have you been in contact with anyone who has tested positive for COVID-19 in the last 14 days?

10. Do you (or anyone in your household) qualify as high-risk according to the most current (as of today) CDC COVID-19 recommendations?

Yes

1. Are you feeling healthy and well today?

2. Are you currently taking an antibiotic?

3. Are you currently taking any other medication for an infection?

4. Do you have any respiratory symptoms today? (e.g., sneezing, coughing, runny nose, sore throat, etc.; THIS INCLUDES ALLERGY SYMPTOMS)

5. Have you had a headache or a fever in the last 48 hours?

6. Do you have muscle aches or body aches today?

7. Have you been in contact with anyone displaying ANY of the above symptoms in the past 14 days?

8. Have you traveled outside the country in past 30 days?

9. Have you been in contact with anyone who has tested positive for COVID-19 in the last 14 days?

10. Do you (or anyone in your household) qualify as high-risk according to the most current (as of today) CDC COVID-19 recommendations?

DISCLAIMER: If you answered YES to any question 2-9, we ask that you refrain from entering the building/classroom/practice area at this time.

I acknowledge that the answers above are true and accurate today.

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