Request edit access
Chicago Riot Rugby COVID-19 Symptom Checker
This form must be utilized prior to attending a training or competition event to ensure that you are free from COVID-19 symptoms and pose limited risk to others.
Sign in to Google to save your progress. Learn more
Email *
Name *
Date *
MM
/
DD
/
YYYY
Are you currently diagnosed with or believe you may have COVID-19 *
Have you had any of these symptoms of COVID-19 in the past ten (10) days? High temperature (fever), new continuous cough, or a new unexplained shortness of breath? *
Have you been in contact with a COVID-19 confirmed or suspected case in the previous ten (10) days? *
Players should be tested for COVID-19 prior to competition, no less than twice per week. Alternatively, participants may be "fully vaccinated" as defined by the CDC. Do you meet one or more of the preceding statements? *
By checking the below box, I attest that all questions were answered honestly to the best of my ability. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy