Event Health Questionnaire
Please complete this mandatory self assessment prior to attending an Arch Street event. If you answer "yes" to any of the following questions, before you go anywhere please contact your health care professional.
Name:
*
First Name
Last Name
Email:
*
example@example.com
Grade:
*
Please Select
6TH
7TH
8TH
9TH
10TH
11TH
12TH
School:
*
Event Date:
*
/
Month
/
Day
Year
Date
Have you tested positive for COVID-19 in the past 14 days?
*
Please Select
Yes
No
Have you had any close contact with a confirmed or suspected COVID-19 case in the past 14 days?
*
Please Select
YES
NO
Do you have a temperature of 100°F or greater?
*
Please Select
YES
NO
Are you experiencing any new or unexpected symptoms?
Cough
Shortness of breath
Difficulty breathing
Muscle or body aches
Sore throat
Diarrhea
Headache
Fatigue
Nausea
New loss of taste or smell
Congestion or runny nose
Vomiting
Fever or chills
I am not experiencing any of the above symptoms
Have you traveled to any of the following states or US territories for 24 hours or longer in the last 14 days? (Alabama, Alaska, Arkansas, California, Delaware, Florida, Georgia, Guam, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Montana, Nebraska, Nevada, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin)
*
Please Select
YES
NO
Date of Completion:
-
Month
-
Day
Year
Date
Please Sign Below:
*
By signing and submitting this form, you certify that the above answers are true to the best of your knowledge and belief.
Submit
Should be Empty: