Section 1 of 1
FH78-06 Weekly Health Survey
Complete for practice on 10/20/2020
Today's date:
Today's date:
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Player/Volunteer Full Name (ie. Erin Madson): *
Player/Volunteer Full Name (ie. Erin Madson): *
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email address:
email address:
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Paragraph
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Time
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Are you or your player currently experiencing a fever (100.4 or higher) or have a sense of a fever?:
Are you or your player currently experiencing a fever (100.4 or higher) or have a sense of a fever?:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes (you must remain at home)
No
Add option
or
add "Other"
…
Answer key
(0 points)
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Do you or your player have a new cough that cannot be attributed to another health condition?:
Do you or your player have a new cough that cannot be attributed to another health condition?:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes (you must remain at home)
No
Add option
or
add "Other"
…
Answer key
(0 points)
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Do you or your player have shortness of breath that cannot be attributed to another health condition?:
Do you or your player have shortness of breath that cannot be attributed to another health condition?:
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes (you must remain at home)
No
Add option
or
add "Other"
…
Answer key
(0 points)
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Do you or your player have new chills that cannot be attributed to another health condition?
Do you or your player have new chills that cannot be attributed to another health condition?
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes (you must remain at home)
No
Add option
or
add "Other"
…
Answer key
(0 points)
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Do you or your player have a new sore throat that cannot be attributed to another health condition? *
Do you or your player have a new sore throat that cannot be attributed to another health condition? *
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes (you must remain at home)
No
Add option
or
add "Other"
…
Answer key
(0 points)
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To the best of your knowledge, have you or someone in your household or close proximity been exposed to Covid-19 in the past 14 days? *
To the best of your knowledge, have you or someone in your household or close proximity been exposed to Covid-19 in the past 14 days? *
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes (you must remain at home)
No
Add option
or
add "Other"
…
Answer key
(0 points)
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I/My player will be at practice tomorrow
I/My player will be at practice tomorrow
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Paragraph
Multiple choice
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Dropdown
File upload
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Multiple choice grid
Checkbox grid
Date
Time
Yes
No
Add option
or
add "Other"
…
Answer key
(0 points)
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