CBC DAILY HEALTH QUESTIONNAIRE
All players MUST complete this questionnaire before EVERY event
Email address *
DATE YOU FILLED THIS OUT *
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TIME YOU FILLED THIS OUT *
Time
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PLAYERS LAST NAME *
PLAYERS FIRST NAME *
WHAT GRADE IS YOUR PLAYER IN? *
WHICH HIGH SCHOOL ARE YOU ZONED FOR? *
MOBILE NUMBER *
REQUIRED DAILY HEALTH CHECK QUESTIONS
Please review the following questions and respond below:

In the past 24 hours have you or anyone in your house had:
• A temperature of 100°F or above?
• New cough that cannot be attributed to another health condition?
• New shortness of breath that cannot be attributed to another health condition?
• New sore throat that cannot be attributed to another health condition?
• Gastrointestinal symptoms (diarrhea, nausea, vomiting) that cannot be attributed to another health condition?
• New nasal congestion or new runny nose?
• New loss of smell and or taste?
• New muscle aches?
• Any other sign of illness?
• Contact with someone in the previous 14 days with confirmed diagnosis of COVID-19 or someone who is ill with a respiratory illness?
DID YOU ANSWER "YES" TO ANY OF THE QUESTIONS ABOVE? *
A copy of your responses will be emailed to the address you provided.
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