GUESTS Covid19 Daily Pool Health Screening Questions

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Email *

Swimmer Name *

Squad *

SRD

GUEST

Other:

Phone Number *

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer) *

Yes

Cough *

Yes

Shortness of breath or difficulty breathing *

Yes

Sore throat *

Yes

New loss of taste or smell *

Yes

Chills, Head or muscle aches, Nausea, diarrhea, or vomiting *

Yes

If you answered yes to any of the following, please do not attend practice until you have either gone 72 hours with no symptoms, or have gotten cleared by your healthcare professional

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

Yes

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *

Yes

Have you been tested for COVID-19 and are waiting to receive test results? *

Yes

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms? *

Yes

In the past 14 days, have you been on a commercial flight or traveled outside of the United States? *

Yes

If you answered yes to any of the following, please do not attend practice until you have gotten cleared by your healthcare professional or quarantined for 14 days

I hereby certify that the responses provided above are true and accurate to the best of my knowledge. (entering your name counts as your signature) *

YYYY

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.

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