Wellness Self Assessment

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This form is designed for individuals connected with our athletic programs to report their self screening for potential illness symptoms. *IF THE ANSWER IS "YES" TO ANY OF THE FOLLOWING QUESTIONS, INDIVIDUALS SHOULD NOT ATTEND ACTIVITIES ON THAT DATE. STUDENTS WILL NEED TO REMAIN HOME FOR 3 DAYS AND GAIN A DOCTORS NOTE TO RETURN TO ACTIVITY FOR A FEVER OVER 100.*

Email *

Last name *

First name *

Program *

Baseball

Boys Lacrosse

Boys Tennis

Boys Volleyball

Girls Lacrosse

Girls Tennis

Golf

Outdoor Track

Softball

Other

Temperature is Over 100 degrees *

YES

Fever or chills *

YES

Cough *

YES

Nasal Congestion or Runny Nose *

YES

Sore Throat *

YES

Shortness of Breath or Difficulty Breathing *

YES

Dairrhea *

YES

Nausea or Vomiting *

YES

Fatigue *

YES

Headache *

YES

Muscle or Body Aches *

YES

New Loss of Taste or Smell *

YES

In the past 14 days, have you traveled to or returned from any of the CT Travel Advisory states? For a full list, please use this link. https://portal.ct.gov/Coronavirus/Covid-19-Knowledge-Base/Travel-In-or-Out-of-CT *

Yes

If 'yes' to above, have you produced a negative COVID-19 PCR test since your return? *

Yes

N/A

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