Conrad Student Health Assessment
A student-athlete who answers "yes" to one or more of questions 5 - 16 below should not report to the practice or competition on the date indicated and may not return to any interscholastic athletic activities until Conrad receives written verification of the student-athlete’s negative polymerase chain reaction (PCR) test for COVID-19 and the student-athlete is cleared by the Delaware Division of Public Health. Student should email Athletic Director Pat Williamson (Patrick.Williamson@redclay.k12.de.us) and the Head Coach of their sport for assistance and support.
Sign in to Google to save your progress. Learn more
Email *
Student Last Name *
Student First Name *
Date of today's Practice/Competition *
MM
/
DD
/
YYYY
Select your Current Sport *
In the last 14 days, have you been near (within 6ft for at least 15 minutes) a person who has a lab-confirmed case of COVID-19, or have you had direct contact with their mucus or saliva? *
0 points
In the last 48 hours have you had a Fever of 100.4 F or above (or symptoms like alternating shivering and sweating)? *
0 points
In the last 48 hours have you had a new cough? *
0 points
In the last 48 hours have you had a new trouble breathing/shortness of breath or severe wheezing? *
0 points
In the last 48 hours have you had a new chills or shaking with chills? *
0 points
In the last 48 hours have you had any new muscle aches? *
0 points
In the last 48 hours have you had a sore throat? *
0 points
In the last 48 hours have you had vomiting or diarrhea? *
0 points
In the last 48 hours have you had new loss of smell/taste or a change in taste? *
0 points
In the last 48 hours have you had nausea? *
0 points
In the last 48 hours have you had fatigue? *
0 points
In the last 48 hours have you had headache, congestion, runny nose with no other known cause (such as allergies)? *
0 points
Have you been in close contact (eg: within 6 ft for more than a few minutes) with a person with confirmed Covid-19 Infection? *
0 points
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Red Clay Consolidated School District. Report Abuse
Google Forms