Daily Health Form
As part of our approved plans for middle school athletics, this survey will be distributed daily to monitor the health of our student-athletes. Parents/Guardians should complete the screening each day for their child(ren) prior to reporting to their scheduled practice or game. Results will be accessible daily by coaches, athletic trainers, and athletic directors for review prior to allowing athletes/staff members to participate. Coaches will also take attendance at all practices.
** SURVEY NEEDS TO BE COMPLETED DAILY by 1:00 pm. If your answer is "Yes" to any question 7-10, or if your child's temperature is 100.4 or higher, please keep them home! They will not be permitted at practice.
Sign in to Google
to save your progress.
1. Today's Date (MM/DD/YY)
3. Student Last Name
2. Student First Name
Track and Field
7. In the past 72 hours, have you or anyone in your household experienced any of the following symptoms related to COVID-19.
Fever(100.4 or higher) or chills
Shortness of breath or difficulty breathing
Muscle or body aches
New loss of taste or smell
Congestion or runny nose
Nausea or vomiting
8. In the past 14 days, have you had close contact with anyone who tested positive for COVID-19, is in the process of being tested for COVID-19, is isolating as a result of suspected COVID-19 infection, or is experiencing acute symptoms of COVID-19?
9. Have you or anyone in your household traveled to one of the states listed below in the past 14 days? Alabama,Arkansas,Florida,Georgia,Idaho,Illinois,Iowa,Kansas,Kentucky,Mississippi,Missouri,Nebraska,North Dakota,Oklahoma,South Carolina,South Dakota,Tennessee,Texas,Utah,Wisconsin
10. Has family coming from one of these states stayed in your residence in the past 14 days?
Student temperature today: (If 100.4 or higher, please stay home).
Never submit passwords through Google Forms.
This form was created inside of Centennial School District.