Varsity Boys Golf-Pine Bush Athletics Daily Health Screening Survey
All Student-Athletes AND Coaches must complete this health screening survey in order to participate in a Pine Bush athletic activity (practice/contest).  This must be completed on the day of participation before 12:00 noon.  
Sign in to Google to save your progress. Learn more
Last Name *
First Name *
Please read the following questions carefully and completely:
1. In the past 10 days, have you experienced any of the following symptoms of COVID-19, including but not limited to, a fever over 100.0 degrees F? (Cough, Shortness of breath, Difficulty breathing, Fever (over 100.0 degrees F), Chills, Repeated shaking with chills, Headache, Sore throat, New loss of taste or smell, Congestion or runny nose, Nausea or vomiting, Diarrhea)

2. Have you tested positive for COVID-19 in the last 10 days?

3. Have you been told to quarantine by a medical professional or Department of Health representative in the last 10 days?

4. In the last 10 days, have you knowingly been in close or proximate contact with an individual who has tested positive for COVID-19?

5. Has anyone in your home been infected with COVID-19 within the past 10 days or is currently waiting for results from a COVID-19 test?

6. In the last 10 days, have you traveled from a country that has been identified as high risk by New York State and/or the Federal Government, which requires a mandated self-quarantine period?
By choosing "No", you are responding "No" to ALL 6 questions listed above. If you have answered "Yes" to any of the 6 questions, please select "Yes" below and do not attend today's activity. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pine Bush Central School District. Report Abuse