USD 379 CCCMS: KSHSAA STUDENT-ATHLETE PRE-PARTICIPATION COVID-19 QUESTIONNAIRE

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Based on awareness of potential cardiopulmonary issues in adolescents who have had or been exposed to COVID-19,
the American Medical Society for Sports Medicine, the National Federation of High School Associations and the
KSHSAA Sports Medicine Advisory Committee recommend a preseason screening of students prior to participating in
athletics.
This questionnaire is to be completed and turned in to the school prior to the student’s first sports practice (including
Spirit) of the 2020-21 school year. It is recommended students/parents complete this form 1-2 weeks prior to the
start of the season in case follow-up evaluation is necessary. If timing allows it should be done in conjunction with the
student’s pre-participation physical exam. This form is NOT intended to replace the recommended daily screening
procedures for all students participating in activities.

http://www.kshsaa.org/Public/COVID/PDF/Questionnaire.pdf

Resources: Drezner JA, Heinz WM, Asif IM, Batten CG, Fields KB, Raukar NP, Valentine VD, Walter KD. Cardiopulmonary considerations for high school student-athletes during the COVID-
19 pandemic: NFHS-AMSSM guidance statement. Sports Health: A Multidisciplinary Approach (SPH). [published online July 9, 2020].

Student Name: *

Date: *

YYYY

Please check Yes or No for each question and symptom listed below.

Have you been diagnosed with or tested positive for a COVID-19 infection? *

Yes

If YES, date of diagnosis or positive test result: _____________________________

Have you had any of the following symptoms in the past two weeks?

Fever *

Yes

Cough *

Yes

Shortness of breath or difficulty breathing *

Yes

Shaking chills *

Yes

Chest pain, pressure, or tightness with exercise *

Yes

Fatigue or difficulty with exercise *

Yes

Racing heart rate *

Yes

Unusual Dizziness *

Yes

Loss of taste or smell *

Yes

Sore throat *

Yes

Nausea, vomiting, or diarrhea *

Yes

Unusual rash or painful discoloration of fingers or toes *

Yes

Do you have a family member or household member with current or past COVID-19? *

Yes

Any student-athlete marking any of the above questions or symptoms “YES” should be evaluated by a healthcare provider and submit written clearance from their healthcare provider to the school before being permitted to participate in sports (including Spirit activities). If this applies to you, we will be contacting you to fill out the second page of this form.

Electronic Student Signature *

Electronic Parent/Guardian Signature *

Email for Parent/Guardian *

Phone # for Parent/Guardian *

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