Self-Assessment Questionnaire
Coronavirus (COVID-19) Self-Assessment helps you check yourself for coronavirus symptoms.

This self-checker is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a medical professional for serious symptoms or emergencies.
You must answer the following questions no more than 24 hours prior to participating in any activity with Kickit365.
Email address *
What is your team name? *
Participant First & Last Name *
Phone Number *
1. Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus? *
If you answered "yes" to question #1 you are subject to the SF Health Order Directive. DO NOT GO TO THE FIELD and contact Kickit365 manager at admin@kickit365.com immediately.
2. In the past 10-14 days have you been in "close contact" with anyone that has COVID-19 during their contagious period? *
If you answered "yes" to question #2 you are subject to the SF Health Order Directive. DO NOT GO TO THE FIELD and contact Kickit365 manager at admin@kickit365.com immediately.
“Close contact” means having any of following interactions with someone with COVID-19 while they were contagious (they are
contagious 48 hours before their symptoms began until at least 10 days after the start of symptoms). If the person with COVID-19 never had symptoms, they are contagious 48 hours before their COVID-19 test was collected until 10 days after they were tested.
- Within 6 feet of them for a total of 15 minutes or more in a 24-hour period
- Living or staying overnight with them
- Having direct contact with their bodily fluids (coughed or sneezed on you or shared food utensils)
- Having physical or intimate contact including hugging and kissing
- Taking care of them, or having them take care of you
3. In the last 24 hours (including today) have you had ANY of the symptoms below, which is new or not explained by other condition? *
Yes
No
Fever (100.4 F or 38 C or greater)
Chills or Repeated Shaking/Shivering
Cough
Sore Throat
Shortness of Breath
Difficulty Breathing
Feeling Unusually Weak or Fatigued
Loss of Taste or Smell
Muscle or Body Aches
Headache
Runny or congested nose
Diarrhea
Nausea
Vomiting
If you answer is "Yes" to ANY symptom in question #3, DO NOT COME TO THE FIELD you might have COVID-19. Contact your healthcare provider about getting tested for the virus, or sign up for free testing at CityTestSF. Wait for your test results at home while minimizing exposure to those you live with. If your result is positive DO NOT COME TO THE FIELD. If your result is negative, DO NOT COME TO THE FIELD - see chart below for next steps. Consult with your healthcare provider and also contact the Kickit365 manager at admin@kickit365.com. All information provided will remain confidential.
Overview of next steps:
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