King Philip Little League COVID-19 Screener

Date *

MM

/

DD

/

YYYY

Name of child *

Team Name & Manager (or event) *

Name of person completing form *

HAVE YOU HAD ANY OF THE FOLLOWING SYMPTOMS IN THE PAST THREE DAYS THAT ARE NOTEXPLAINED 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 Vomiting

Diarrhea

Runny Nose or Stuffy Nose

Fatigue

Recent Loss of Taste or Smell

RISK FACTORS *

Yes

No

Have you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days? *Does not apply to people who come into contact with people with symptoms of COVID-19 during the course of their daily risk while wearing full and appropriate personal protective equipment (PPE). See https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html for more information.

Have you traveled anywhere outside the 50 United States in the past 14 days?

Have you traveled to Rhode Island for a non-work-related purpose from another city, town, county, or state that currently has a stay-at-home restriction, a shelter-in-place restriction, or a similar restriction, declaration, or announcement due to a COVID-19 outbreak? *Public health, public safety, and healthcare workers are exempt. Does not apply to anyone traveling for medical treatment, to attend funeral or memorial services, to obtain necessities like groceries, gas, or medication, to drop off or pick up children from day care, or to anyone who must work on their boats.

Have you been directed to quarantine or isolate by the Rhode Island Department of Health or a healthcare provider in the past 14 days? If so, when does/did your quarantine or isolation period end?

Yes

No

Have you been in close contact (less than six feet) with anyone with COVID-19 or symptoms of COVID-19 in the past 14 days? *Does not apply to people who come into contact with people with symptoms of COVID-19 during the course of their daily risk while wearing full and appropriate personal protective equipment (PPE). See https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html for more information.

Have you traveled anywhere outside the 50 United States in the past 14 days?

Have you traveled to Rhode Island for a non-work-related purpose from another city, town, county, or state that currently has a stay-at-home restriction, a shelter-in-place restriction, or a similar restriction, declaration, or announcement due to a COVID-19 outbreak? *Public health, public safety, and healthcare workers are exempt. Does not apply to anyone traveling for medical treatment, to attend funeral or memorial services, to obtain necessities like groceries, gas, or medication, to drop off or pick up children from day care, or to anyone who must work on their boats.

Have you been directed to quarantine or isolate by the Rhode Island Department of Health or a healthcare provider in the past 14 days? If so, when does/did your quarantine or isolation period end?

IF YOU HAVE ANSWERED “YES” TO ANY OF THE QUESTIONS ABOVE, AND YOU CANNOT EXPLAIN THESE SYMPTOMS BY KNOWN ALLERGIES OR NON-INFECTIOUS ILLNESSES, THEN THE PERSON SHOULD BE EXCLUDED FROM THE FACILITY AND SHOULD SELF QUARANTINE UNTIL 14 DAYS HAVE PASSED SINCE THE TIME OF POTENTIAL EXPOSURE / TRAVEL.