BEFORE CLASS SCREENING

BEFORE CLASS SCREENING

Please submit this form the day of your class and before class begins.
Athlete Name*
Athlete or Parent Email for Contact Tracing *
example@example.com
Athlete Phone Number (if applicable)
School Name (No Abbreviations)*
Do NOT abbreviate. Please write out full school name.
Class Date (Today's Date)
DO YOU HAVE SYMPTOMS OF COVID-19? (Self Declaration: Symptoms of COVID-19)

Select below any and all new or unusual symptoms you have experienced in the past 72 hours. If you have not experienced any of these symptoms, select "None of these symptoms"

“Symptoms of COVID-19” means at least 1 of fever, uncontrolled cough, or atypical new onset of shortness of breath, or at least 2 of the following not explained by a known physical condition: loss of taste or smell, muscle aches, sore throat, severe headache, diarrhea, vomiting, or abdominal pain. Per section 1(h) of 2020 PA 238, this definition represents the latest medical guidance, and serves as the controlling definition.
NONE OF THESE SYMPTOMSFeverUncontrolled CoughAtypical Shortness of BreathLoss of Taste or SmellMuscles AchesSore ThroatSevere HeadacheDiarrheaVomitingAbdominal Pain
HAVE YOU BEEN IN CLOSE CONTACT WITH COVID-19? (In the last 14-days, have you had close contact with a person that has been suspected or confirmed of being infected with COVID-19?)

Close contact is someone who was within 6 feet of an infected person for at least 15 minutes starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to specimen collection) until the time the patient is isolated.
NoYesYes, however, I'm fully vaccinated (2 weeks since 2nd dose)
Should be Empty: