BTBKL Health Screen & Attendance Form
Must be completed each week prior to joining BTBKL practice
* Required
Name/s
*
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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