Daily Covid-19 Screening Form

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Please complete this before each practice AND game

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عنوان بريد إلكتروني *

Childs Name *

Date

شهر

YYYY

In the past 14 days, have you been near(within 6 feet for at least 15 minutes) a person who has a lab-confirmed case of Covid-19, or have you had direct contact with either the mucus or saliva of that individual? *

Yes

مطلوب

In the past 48 hours, have you had any of the following symptoms? PLEASE CHECK ALL THAT APPLY

Fever 100.4 or above(or related symptoms such as shivering and sweating)

New Cough

Trouble breathing or shortness of breath

Chills

New Muscle Aches

Sore throat

Vomiting or diarrhea

Loss of smell or taste; change in taste

Nausea

Fatigue

Headache, congestion, or runny nose with no other known causes

NO--I have not experienced any of these symptoms in the past 48 hours

Before leaving for practice, do you have a fever of 100.4 or above

Yes

محو التحديد

If you answered YES to any of the questions above, DO NOT report to practice. Please contact your coach and your family doctor.

سيتم إرسال نسخ من ردودك عبر البريد الإلكتروني إلى العنوان الذي قدمته

إرسال

محو النموذج

عدم إرسال كلمات المرور عبر نماذج Google مطلقًا.

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