Student Athlete COVID-19 Self Screening Survey
All student athletes must complete the following questionnaire prior to coming each training day. Submission of this form must be provided to the coach or activity supervisor. If you have any of these symptoms, you will not be allowed to participate, should self-isolate, and contact your primary care provider or other health care professional.
Have you received a COVID-19 vaccine?
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Yes
No
Have you received a COVID-19 test in the last 14 days?
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Yes
No
Have you been in contact with a novel coronavirus (COVID-19) infected person in the last 10 days?
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Yes
No
Have you had any two or more of the following symptoms in the last 7 days?
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Yes
No
Symptoms
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Yes
No
Fever/Temperature above normal
New Cough
Short of Breath
Loss of Smell
New abdominal Pain
Diarrhea
Stuffy or Runny Nose
Fatigue
Muscle and joint pain
Headache
Feeling Generally unwell
Consent
I understand that I must submit this health screening document before each practice day. I will notify the coach or activity supervisor daily if I develop any of the above symptoms. I understand that if I have a temperature above 38 I will need to stay home for at least 72 hours and must be fever free for 72 hours without fever reducing medications before returning to practice. If COVID is suspected based on my symptoms I must stay out of practice for at least 10 days after symptoms begin. I must get a doctor’s note to return to practice. I (parent/guardian) understand that if my child gets sick during practice, I will either pick him/her up or designate an emergency contact to do so.
Name
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First Name
Last Name
Date:
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Year
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Month
Day
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Parent Signature
Sign in box above.
Phone Number
Student Signature
Sign in box above.
Date
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Year
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Month
Day
Date
Emergency Contact Name:
First Name
Last Name
Emergency Contact Phone Number
Submit
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