Covid 19 Screening Form

Covid 19 - Screening Form

Complete this form if you plan to attend an in-person DCMGA event, EVEN IF YOU HAVE RECENTLY HAD THE COVID-19 VACCINATION.
Which project are you planning to attend:
COVID-19 Screening Form

Due to the COVID-19 pandemic, and in an attempt to minimize the spread of the virus, Texas A&M AgriLife Extension Service is required to screen all youth, staff, and visitors participating in a youth day or overnight event. In order to be granted access to events, all visitors must truthfully complete and submit the following:

I, {name}, hereby affirm that:
Name

First Name Last Name
1. While at the event I will maintain a minimum of 6 feet of separation from any other individuals not within my household.
2. I have not in the past 7 days exhibited any of the known symptoms of COVID-19, including:
  __ Cough
  __ Shortness of breath or difficulty breathing
  __ Chills
  __ Repeated shaking with chills
  __ Unexpected muscle pain
  __ Headache
  __ Sore throat
  __ Loss of taste or smell
  __ Diarrhea
  __ Running a fever (or measuring a temperature of 100.0 degrees Fahrenheit or more)
3. In the past 14 days I have not been in contact with any person known to have contracted COVID-19.
I understand face coverings (over the nose and mouth), or non-medical grade face masks are required per the Governor’s Resolution GA-29 on July 2, 2020. I also understand that it is recommended that I follow the minimum standard health protocols issued by the Texas Department of State Health Services and cited by the Texas Governor in his Executive Orders related to the pandemic.

I understand that the virus that causes COVID-19 can be spread to others by infected persons who have few or no symptoms. Even if an infected person is only mildly ill, the people they spread it to may become seriously ill or even die, especially if that person is 65 or older with pre-existing health conditions that place them at higher risk. Because of the hidden nature of this threat, everyone should rigorously follow the practices specified in the DSHS protocols, all of which facilitate a safe and measured reopening of Texas. The virus that causes COVID-19 is still circulating in our communities. We should continue to observe practices that protect everyone, including those who are most vulnerable.

I understand that AgriLife Extension cannot guarantee that I will not contract the virus, even when implementing screening protocols. I further understand that safety is a shared duty, COVID-19 is a shared risk, and all community members, including visitors, must take steps to promote health and safety. I acknowledge that I am assuming the risk that I may contract the virus by entering facilities, even when screening protocols and mitigation measures are implemented.

I understand that AgriLife Extension is required to have this attestation in order for me to attend events sponsored by them and I sign below to confirm the truth of the above.
Name

First Name Last Name
Date

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Phone Number
Please enter a valid phone number.
Email
example@example.com
Signature

Clear
Should be Empty:

Covid 19 - Screening Form