AFA Athlete COVID-19 Self Screening Questionnaire

AFA Athlete COVID-19 Self Screening Questionnaire

Indoor program self screening checklist
You must answer “NO” to all the questions in this questionnaire in order to enter our indoor Sport HQ facility. If you answer “YES” to any of the questions, please DO NOT report to Sport HQ and contact Stephanie at stephanie@thealphafemaleathlete.com.

1) Have you had any of the following symptoms in the last 24 hours?

Rows	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:

Rows	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

2) In the last 14 days have you:

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come into the Sport HQ facility.

I certify to the best of my knowledge; this information is accurate.
Parent Signature
Athlete Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: