Skyliners SST Health Questionnaire (submit on the day of each practice, due 2 hours before practice start)
Version : 7/22/2020
BEFORE EACH AND EVERY PRACTICE AT LEAST 2 HOURS BEFORE THE START TIME OF THE PRACTICE, please 1) take the temperature of the Skater (or Coach if Coach completing this questionnaire) and 2) complete this questionnaire . It is important to be honest in completing this questionnaire. It will assist us in trying to keep all of our skaters safe. If any of the information changes, it is your responsibility to immediately notify us at ReportingCovid@SkylinersSynchro.com or 914-200-4577 (Skyliners’ COVID reporting hotline).
Email address *
Today's Date: *
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Enter Full Name of Skater (or if you are a Coach enter your own name) : *
Skaters’s Line (or if you are a coach select COACH): *
1) I have taken the temperature of my skater (or myself if a Coach) immediately prior to completing this questionnaire. *
2) Has the Skater / Coach (or anyone in the household where the Skater / Coach resides) had a temperature higher than 100.4 degrees Farenheit in the last 14 days. *
3) Has the Skater / Coach (or anyone in the household where the Skater / Coach resides) experienced any of the symptoms commonly associated with COVID-19 or any other cold or flu-like symptoms, in the last 14 days, including fever, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, and or new loss of taste and/ or smell (a full list of symptoms can be found at the CDC website : https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html)? *
If you answered yes to #3, are these symptoms persisting? Or when did they cease?
4) Has the Skater / Coach (or anyone in the household where the Skater / Coach resides) tested positive, or otherwise been diagnosed with COVID-19, or had contact with or cared for someone with COVID-19, within the last 30 days? *
If yes to #4, list the date person was diagnosed or last tested positive, whichever is later:
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If yes to #4, list the date Skater / Coach last had contact with the person diagnosed or anyone who was exposed to the person diagnosed:
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If you answered yes to #4, has the Skater / Coach had an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA?
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If your skater has had a test, please provide the date(s) of each test and the result:
5) Does the Skater / Coach reside or has the Skater / Coach (or anyone in their household) spent time in the last 14 days in, or traveled to, any country or state for which there is a travel advisory for Connecticut (if practice is in Connecticut), for New York (if practice is in New York) or for New Jersey (if the practice is in New Jersey)? For a current list of states subject to the travel advisory, please visit each state's travel advisory webpage (links are included in the Skyliners COVID-19 protocols sent out to all families) *
If you answered yes to #5, is the Skater / Coach in compliance with all requirements for entering CT (if the practice will be in CT), NY (if the practice will be in NY) or NJ (if the practice will be in NJ)? To find the applicable requirements, please visit each state's travel advisory webpage (links are included in the Skyliners COVID-19 protocols sent out to all families)
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ELECTRONIC SIGNATURE - By entering your name below you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request to sign a paper copy instead. By entering your name below you are waiving that right. After consent, you may, upon request, receive a paper copy of the electronic record. No fee will be charged and no special hardware or software is required to view it. PLEASE ENTER THE FULL LEGAL NAME OF THE PARENT/GUARDIAN (OR SKATER IF THE SKATER IS 18 OR OLDER) COMPLETING THE QUESTIONNAIRE: *
Relationship to Skater of person completing questionnaire:
Press SUBMIT below.
A copy of your responses will be emailed to the address you provided.
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