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ADULT - 2021 CYO COVID19 SCREENING QUESTIONNAIRE DIOCESE OF BROOKLYN
In order to continue providing the safest environment possible for our players, coaches, staff and officials, we ask that you fill out the below survey with information about yourself and your child prior to attending any CYO practices and games.
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Date
MM
/
DD
/
YYYY
Your Name
Your answer
Phone #
Your answer
Location
Your answer
Game Time
Your answer
Child's Name (if you will be a spectator)
Your answer
Your Temperature
Your answer
In the past 24 hours, have you experienced a fever above 100.3?
Yes
No
Clear selection
Are you exhibiting any of the following symptoms?
Fever, chills, shortness of breath, difficulty breathing, worsening cough, sore throat, diarrhea, nausea, vomiting, headache, or loss of taste or smell
Yes
No
Clear selection
Is anyone in your household experiencing any of these symptoms? Fever, chills, shortness of breath, difficulty breathing, worsening cough, sore throat, diarrhea, nausea, vomiting, headache, or loss of taste or smell
Yes
No
Clear selection
Have you been in close contact in the last 14 days with someone diagnosed with COVID-19?
Yes
No
Clear selection
If you have answered YES to any of the above Questions – You are prohibited from attending today’s scheduled CYO event
Certification: I hereby certify that the responses provided above are true and accurate to the best of my knowledge:
By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.
Your answer
Note: The information on this form will be maintained as confidential.
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