BTBKL Health Screen & Attendance Form

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BTBKL Health Screen & Attendance Form

Must be completed each week prior to joining BTBKL practice

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* Required

Micayla Shefftz, Andrea Newman, Jonathan Shefftz *

Your answer

Select All that apply to you and/or any household members *

Current Pending COVID-19 test prompted by symptoms

Positive COVID-19 test within the past 14 days

Traveled out-of-state within the past 14 days or live outside of MA

Close contact (within 6 feet for a total of at least 15 minutes over 24 hours) with a person with confirmed COVID-19?

None of the above

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