COVID-19 Athlete & Volunteer Questionnaire

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To be completed prior to attending, training sessions and competitions.

CONFIDENTIALITY
All information is provided in strict confidence and will not be shared with others. If information provided requires further clarification you will be contact prior to the session/competition.

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Courriel *

First & Last Name *

Telephone Number *

Countries you visited or stayed in the last 14 days *

Have you had close contact with anyone diagnosed as having COVID-19? *

Yes

Have you or a co-resident provided direct care for COVID-19 patients? *

Yes

Visited or stayed in a closed environment with any patient having COVID-19? *

Yes

Worked together in close proximity, or sharing the same classroom environment with a COVID-19 patient? *

Yes

Traveled together with a COVID-19 patient in any kind of conveyance? *

Yes

Lived in the same household as a COVID-19 patient? *

Yes

Have you stayed in a Government quarantine or isolation centre or home isolated? *

Yes

If you answered yes to the question above, when were you released?

How many doses of the COVID vaccine have you received? *

None

Did you arrive to Barbados on an airplane within the last two weeks? *

Yes

If you arrived by airplane within the last two weeks what was the date and result of last COVID test?

Experienced any of the the following symptoms now and in the previous 14 days: *

Yes

Cough

Sore throat

Chest pain

Congestion/Coryza

Headache

Chills

Nausea/Vomiting

Diarrhea

Anosmia (loss of smell)

Dysgeusia/Ageusia/hypogeusia (distortion of taste, loss of taste, decrease in taste sensitivity)

Chilblains/Pernio (itching, red patches, swelling and blistering of the skin)

Are you or do you have any of the following? *

Yes

Diabetes

Asthma

Chronic lung disease

Heart conditions

Chronic kidney disease

Liver disease

Immunocompromised (weakened immune system)

Hypertension

OVER 65

Are there any injuries current or recent that may affect your ability to perform physical activity? *

Name of person completing the form, if form is for a person under the age of 18, a parent/guardian must attach their name. *

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