FSVBC-Covid 19 Symptom Screening Form

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In accordance with guidelines from the Centers for Disease Control (CDC), the California Department of Public Health (CDPH) and the Yolo County Health Officer, symptom screening is required to reduce the spread of COVID-19.*

Email *

Your FSVBC Team *

18-Jason

17-Todd

16-Dana

Full Name: *

Today's Date: This is the date you actually practiced on site with FSVBC team. *

YYYY

Temperature Check: I have taken my temperature upon arrival and it is BELOW 100.4 Fahrenheit. *

Yes

Are you currently experiencing any of the following NEW OR UNEXPECTED COVID-19 symptoms? (**seek medical care) *

Temperature over 100.4

Chills

NEW Cough

Shortness of breath

Fatigue

Muscle or body aches

Headache

NEW loss of taste or smell

Sore throat

Congestion or Runny nose

Nausea or vomiting

Diarrhea

DIFFICULTY BREATHING **

PRESISTENT PAIN OR PRESSURE IN THE CHEST **

NEW CONFUSION **

INABILITY TO WAKE OR STAY AWAKE **

NONE

Other:

Required

Are you currently taking any NEW medication (prescription or over-the counter) that might mask the symptoms of COVID-19 or symptoms of a respiratory illness? *

Yes

Is anyone in your household, or someone you have come in close contact with, ill or presenting symptoms of COVID-19, diagnosed with COVID-19 or self quarantining/self isolating as ordered by a physician? *

Yes

All indoor practices will require players to wear a mask, which will need to fully cover your nose and mouth, upon entry and exiting of the building and during the entire practice. Will you be wearing a mask today? *

Yes

Have you washed your hands or used alcohol-based hand sanitizer on entry? *

Yes

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

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