CBC DAILY HEALTH QUESTIONNAIRE

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All players MUST complete this questionnaire before EVERY event

Email *

DATE YOU FILLED THIS OUT *

YYYY

TIME YOU FILLED THIS OUT *

Time

PLAYERS LAST NAME *

PLAYERS FIRST NAME *

WHAT GRADE IS YOUR PLAYER IN? *

WHICH HIGH SCHOOL ARE YOU ZONED FOR? *

Clarke County

Woodgrove

Loudoun Valley

Other:

MOBILE NUMBER *

REQUIRED DAILY HEALTH CHECK QUESTIONS

Please review the following questions and respond below:

In the past 24 hours have you or anyone in your house had:
• A temperature of 100°F or above?
• New cough that cannot be attributed to another health condition?
• New shortness of breath that cannot be attributed to another health condition?
• New sore throat that cannot be attributed to another health condition?
• Gastrointestinal symptoms (diarrhea, nausea, vomiting) that cannot be attributed to another health condition?
• New nasal congestion or new runny nose?
• New loss of smell and or taste?
• New muscle aches?
• Any other sign of illness?
• Contact with someone in the previous 14 days with confirmed diagnosis of COVID-19 or someone who is ill with a respiratory illness?

DID YOU ANSWER "YES" TO ANY OF THE QUESTIONS ABOVE? *

No - Time to play some hoops!

Yes - If so, you are NOT permitted to participate. You should not return until you or your family member is fever and symptom-free, without the use of medication for the fever or symptoms for three days.

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

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