Request edit access
SHS Athletics Daily COVID Health Survey
Please answer all questions as accurately as possible before arriving to the school/building. This form MUST be completed prior to arriving to the school for athletic participation. Temperatures will be taken prior to the start of athletic participation daily.
* Required
Email address
*
Your email
Sport
*
Boys Basketball
Girls Basketball
Winter Track
Swim
Wrestling
First Name
*
Your answer
Last Name
*
Your answer
Do you have any of these symptoms that are new, unexpected, or that you cannot attribute to another condition? (Please check off all that apply)
*
Fever equal to or higher than 100.0 or feeling feverish (chills, sweating)
New Cough
Shortness of breath or difficulty
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore Throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
No symptoms
Required
Have you had close contact (within 6 feet for at least 10 minutes) with someone who has tested positive for COVID-19 in the past 14 days?
*
Yes
No
Within the past 14 days, have you traveled to an area subject to a Level 3 CDC Travel Health Notice or to a U.S. state with significant COVID-19 spread, as identified by the NJ Department of Health?
*
Yes
No
Are you under evaluation for COVID-19 (waiting for results of a viral test to confirm infection)?
*
Yes
No
Have you been diagnosed with COVID-19 and not yet cleared to discontinue isolation?
*
Yes
No
Please read the statement below.
If you've answered yes to any questions, stay home, notify your coach, Mrs. Franzwa and Mr. Clarke, and consult with your health care provider. Thank you!
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Pittsgrove Township Schools.
Report Abuse
Forms
