2020 Mid-America Championships Health Screen

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Everyone attending the 2020 Mid-America Championships must submit their own daily health screen in order to enter the ICC. Your health screen can be submitted electronically or as a hard copy. If submitting electronically you must show confirmation of this completed form on your phone when entering the ICC.

Email *

Name *

Date *

YYYY

Have you had contact with with anyone that you know has been diagnosed with COVID-19 in the last 14 days? *

Yes

Have you had a positive COVID test in the past 10 days? *

Yes

Recorded self-temperature *

Time self-temperature was taken *

Time

Do you have any of these symptoms that you cannot attribute to another condition? *

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

Recent onset of loss of taste or smell

Sore throat

Congestion

Nausea or vomiting

Diarrhea

None of the above

Required

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

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