Triumph Gymnastics - COVID-19 Health Screening

At Triumph Gymnastics the safety of our customers and employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities.
In order to prevent the spread of the coronavirus and reduce the potential risk of exposure, we are asking everyone to complete and submit this questionnaire prior to entering our facility.

Please complete the following health screen interview for each person under your care seeking to enter the building (even just to drop off or pick up) each day.

Please complete and return the survey(s) on the day of your scheduled visit at least 1/2 hour before arrival.

Please respond to each of the following questions truthfully and to the best of your ability.
Sign in to Google to save your progress. Learn more
Email *
Enter name of the person for whom the health screen is being completed: * *
1. Do you currently have any of the following new and unexplained symptoms ? (Examples of symptoms that are explained include cough, sore throat, headache associated with seasonal allergies; muscle aches associated with strenuous exercise; etc.) Please indicate by checking the box(es): *
2. In the pst 14 days, have you been tested for COVID-19 and/or are waiting to receive test results? *
3. Have you or someone you live with been in close contact with someone who has a confirmed or suspected COVID-19 case in the past 14 days? *
4. Have you been mandated or advised by a government agency or a physician to isolate or self-quarantine due to personal illness, illness of a close contact, or due to travel to a hot spot, in the past 14 days? *
5. Have you traveled to a High Risk Region or any State required to quarantine by NY Governor Executive Order 205 in the past 14 days? *
New and unexplained symptoms, or a response of "yes", will automatically preclude entry to the gym. You are encouraged to consult with your health care provider and get tested. Per CDC guidelines: *If you have new and unexplained symptoms you should consult a doctor and you should not return until it has been at least 10 days since your symptoms first appeared, and at least 1 day (24 Hours) after resolution of fever without fever-reducing medications and other symptoms have improved, or you have received a negative COVID-19 test. * If you have tested positive for COVID-19, you must notify us, and we are required to report the positive test to the New York State Health Department and the New York City Department of Health and Mental Hygiene. You must self-quarantine for 10 days and be symptom free before returning. * If you have been exposed to a close contact with confirmed or suspected COVID-19, but are not symptomatic, you must self-quarantine for 14 days and be symptom free before returning; if you have been exposed and are symptomatic, you can return after 10 day quarantine. * If you become sick while at Triumph Gymnastics, you agree to immediately notify the front desk. If your child becomes ill in your absence, we will isolate your child from the other children and notify you that your child must be picked up immediately. Please make sure that your contacts and emergency contact information is current.
Please enter the name of the person completing the Health Screening (Parent /Guardian) *if applicable
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy