RCS COVID-19 Health Questionnaire: High School Students
Please complete the following form and report to your teacher / club sponsor if you answer yes to any of the following questions.
First name *
Last name *
School: *
Club, event, or teacher you are here for: *
Grade level *
Parent or guardian name and phone number
Do you have any of the following symptoms of COVID-19: fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, rash, nausea or vomiting, or diarrhea? *
Have you had close contact with or cared for someone with COVID-19 within the past 14 days? Close contact is defined as either being within 6 feet of an infected person for at least 15 minutes, providing care at home to an infected person, direct physical contact with an infected person (touched, hugged, kissed), sharing eating or drinking utensils, or the infected person sneezed, coughed or somehow got respiratory droplets on you. *
Have you traveled outside of the United States within the past 14 days? *
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