COVID-19 Supplemental Health Questionnaire
SSCC PRACTICE IN THE ERA OF COVID-19 IF YOU HAVE BEEN EXPOSED TO A COMMUNICABLE DISEASE, YOU MAY SPREAD THE DISEASE TO A COACH, DIRECTOR, STAFF MEMBER, OR OTHER ATHLETES IN THE PRACTICE, CLINIC, CHEER CAMP OR COMPETITION. THEREFORE, PRIOR TO EACH OF THE ABOVE, WE WILL BE ASKING THE FOLLOWING QUESTIONS TO REDUCE THE CHANCES OF SUBMISSION. PLEASE ANSWER ALL QUESTIONS TRUTHFULLY.
PARENT/GUARDIAN NAME IF UNDER 18
Street Address Line 2
State / Province
Postal / Zip Code
WITHIN THE LAST 14 DAYS HAVE YOU, YOUR CHILD, OTHERS ACCOMPANYING YOU OR YOUR CHILD TO TODAYS EVENT OR ANYONE YOU HAVE RECENTLY BEEN IN CONTACT WITH BEEN DIAGNOSED WITH COVID-19 OR HAD A TEST CONFIRMING THAT YOU OR THEY HAVE HAD THE VIRUS?
IF YES PROVIDE DATE OR APPROXIMATE DATE OF CONTACT OR DIAGNOSIS AND OR DATES OF ILLNESS SYMPTOMS START DATE TO SYMPTOMS END DATE
HAVE YOU OR THE PERSON ACCOMPANYING YOUR CHILD HAD ANY ONE OR MORE OF THESE SYMPTOMS TODAY OR WITHIN THE PAST 24 HOURS, WHICH IS NEW OR NOT EXPLAINED BY ANOTHER REASON? (CHECK ANY THAT APPLY)
FEVER OR CHILLS (Defined as above 100.4 degrees F)
SHORTNESS OF BREATH AND OR DIFFICULTY BREATHING
MUSCLE OR BODY ACHES
NEW LOSS OF TASTE OR SMELL
CONGESTION OR RUNNY NOSE
NAUSEA OR VOMITING
PERSISTENT PAIN, PRESSURE OR TIGHTNESS IN THE CHEST
Have you, your child, others accompanying your or child to today's event or anyone you have recently been in contact with, traveled to and/or from any states on the New Jersey's Travel Advisory List or any countries that should quarantine for 14 days after leaving that state?(New Jersey from states with increasing rates of COVID-19 are advised to self-quarantine for 14 days. This includes travel by train, bus, car, plane and any other method of transportation.)
If yes, what state or country and date did you arrive back from?
I understand that if the answer to any of these questions are yes, participation in this event will be denied until proof of doctor’s clearance or negative test with quarantine. RULES ARE IF COVID-19 POSITIVE YOU ARE TO QUARANTINE 10 DAYS FROM DATE OF FIRST SYMPTOM. IF SYMPTOMS PERSIST CLOSE TO THE 10 DAYS THEN YOU ARE TO QUARANTINE AN ADDITIONAL 3 DAYS FROM THAT LAST SYMPTOM. IF YOU WERE EXPOSED AND DID NOT HAVE SYMPTOMS THEN YOU ARE TO QUARANTINE 14 DAYS FROM DATE OF EXPOSURE.
PLEASE PUT SIGNATURE BELOW - THANK YOU
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