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Covid-19 Daily Pre-Screening Questionnaire Form
To participate in workouts and team practices during Plan C guidelines, each student and coach must complete this form daily before every workout, practice, or game. Screening questionnaires must be completed prior to arriving on school grounds.
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* Indicates required question
Email
*
Your email
Email Address (
joeexample@tmsacahrter.org
)
*
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Sport
*
MS Girls Basketball
MS Boys Basketball
HS Girls Basketball
HS Boys Basketball
HS Cheer
Coach
Are you experiencing any of the following symptoms (Fever (> or = to 100.4, cough or shortness of breath, sore throat, chills, muscle aches or rigors, headache, new loss of taste or smell, abdominal pain, nausea, vomiting or diarrhea)?
*
Your answer
If yes, please list the symptoms experienced. If "No symptoms", please write "No".
Your answer
Have you had close contact with someone who is currently sick?
Yes
No
Clear selection
Have you been diagnosed with COVID-19 in the past three weeks or have reason to believe you have COVID-19?
Yes
No
Clear selection
Have you traveled or had close contact with anyone who has traveled internationally in the last 14 days?
Yes
No
Clear selection
Digital Signatures
*
I attest that all the information contained in this form is true to the best of my knowledge and will update the athletic coaching staff with changes via email notification.
I will wait outside the facility prior to my assigned event with my mask on for a temperature check and recording at the entry to my designated location.
Required
A copy of your responses will be emailed to the address you provided.
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