STS COVID-19 Health Screening Form

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All camp participants must complete this form the day of the event and prior to arrival/check-in.

Participants Last Name *

Participants First Name *

Date *

YYYY

General Symptoms *

Any of the symptoms below could indicate a COVID-19 infection and may put you at risk for spreading the illness to others. Please not that this list does not include all possible symptoms, and individuals with COVID-19 may experience any, all or none of these symptoms. Please check yourself for these symptoms daily and acknowledge whether you are currently exhibiting any of the following symptoms:

Fevers (measured or subjective)

Chills

Rigors (shivers)

Myalgia (muscle aches)

Sore throat

Headache

Nausea and/or vomiting

Diarrhea

Fatigue

Congestion or runny nose

NONE of the above

Required

COVID-19 Symptoms *

Cough

Shortness of breath

Difficulty breathing

New loss of smell

New loss of taste

NONE of the above

Required

Close Contact/Potential Exposure *

You have had close contact (within 6 feet of an infected person for at least 10 minutes) with a person with confirmed COVID-19

Someone in your household is diagnosed with COVID-19

You have traveled to an area of high community transmission

NONE of the above

Required

Acknowledgment *

I verify that my answers are accurate and understand that should I be experiencing two or more general symptoms and/or one or more COVID-19 symptoms and/or be a close contact and/or have recently traveled to an area of high community transmission that I should not attend today's camp but instead contact the camp director at stscamps@gmail.com.

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