2021 Indiana Swimming Speedo Sectional COVID Screening

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2021 Indiana Swimming Speedo Sectional COVID Screening - NON-ATHLETE FORM

NON-ATHLETE FORM

Participant First Name *

Participant Last Name *

To facilitate contact tracing please provide a phone number. *

Are you a(n): *

Coach

Official

Event Staff or Volunteer

ATHELTES MUST COMPLETE THE ATHLETE SCREENING FORM - https://forms.gle/1Yzzqsq6deGtpQgUA

Swim Club / Organization *

In the last 14 days, have you had a positive COVID-19 test? *

Yes

In the last 14 days, have you been in close contact with anyone who has tested positive? *

Yes

Have you had a positive-COVID test for active virus in the past 10days? *

Yes

In the last 72 hours have you had any of the following symptoms: *

Fever greater than 100.4° F

Chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea

Diarrhea

Vomiting

I have not and do not have any of the above symptoms

Required

In the last 24 hours, have you taken fever-reducing or other symptom-altering medicines due to COVID or COVID like symptoms (e.g. ibuprofen, Tylenol, or cough suppressants)? *

Yes

Do you currently have COVID-19, or are you caring for someone who has COVID-19? *

Yes

By checking below I certify that the responses provided above are true and accurate to the best of my knowledge and participation in this event is voluntary. *

By checking below I certify that the responses provided above are true and accurate to the best of my knowledge and participation in this event is voluntary.

Required

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