FPSC Travel Girls Assessment Form

Travel Girls Screening Assessment NYCFC Youth Programs

PLEASE COMPLETE WITH YOUR PARENT/LEGAL GUARDIAN
Screening Assessment (SSA), includes:
 Standardized Screening Questionnaire (if all answers NO, Player/staff will come to the facility. If any answers YES, Player/staff will not come to the facility)
 Documented temperature upon entrance to facility

Standardized Screening Questionnaire (SSQ); should be completed daily and prior to coming to training each day

IF YES TO ANY OF THE BELOW QUESTIONS, PLEASE PROVIDE DETAILS AND CONTACT YOUR YOUTH CLUBS PLAYER ADVOCATE

Player Name *

Team *

Choose your team

Parent Email Address *

example@example.com

Today's Date *

Date

In the past 14 days, have you experienced any Covid-19 symptoms, including but not limited to: (check all that apply) *

No Symptoms Cough Chills or repeated shaking with chills Muscle pain Headache Sore throat Chest pains, palpitations or fatigue New loss of taste or smell

Have you traveled internationally or from a location considered high risk for Covid-19 in the past 14 days? *

Yes No

Have you been exposed in the last 14 days to anyone that has been diagnosed with Covid-19 or had Covid-19 symptoms? *

Yes No

Is there any reason to believe that you may have been exposed to the virus in the last 14 days? *

Yes No

Have you had a documented elevated temperature (>38° C, or 100.4° F) in the last 72 hours? *

Yes No