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CATHOLIC YOUTH ORGANIZATION
DIOCESE OF BROOKLYN/QUEENS
Covid-19 Adult Screening Questionnaire
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* Indicates required question
NAME
*
Your answer
DATE
*
MM
/
DD
/
YYYY
GAME TIME
*
Time
:
AM
PM
LOCATION
*
Your answer
PHONE NUMBER
*
Your answer
CHILD'S NAME (IF YOU WILL BE A SPECTATOR)
Your answer
YOUR TEMPERATURE
*
Your answer
1.
In the past 24 hours, have you or your child experienced a fever above 100.3?
*
YES
NO
2.
Are you exhibiting any of the following symptoms?
Fever, chills, shortness of breath, difficulty breathing, worsening cough, sore throat, diarrhea, nausea, vomiting, headache, or loss of taste or smell
*
YES
NO
3.
Is anyone in your household experiencing any of these symptoms? Fever, chills, shortness of breath, difficulty breathing, worsening cough, sore throat, diarrhea, nausea, vomiting, headache, or loss of taste or smell
*
YES
NO
4.
Have you been in close contact in the last 5 days with someone diagnosed with COVID-19 and has not tested negative?
*
YES
NO
If you answered YES to any of the above Questions – He/She is prohibited from participating in or attending today’s scheduled CYO event –
Certification
I hereby certify that the responses provided above are true and accurate to the best of my knowledge:
SIGNATURE
*
Your answer
DATE
*
MM
/
DD
/
YYYY
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