Racer X Aquatics COVID-19 Screening

First Name *

Last Name *

In the last 14 days, have you had a positive COVID-19 test? *

Yes

In the last 14 days, have you been in close contact with anyone who has tested positive? *

Yes

In the last 72 hours have you had close contact with someone diagnosed with COVID‐19? *

Yes

In the last 72 hours have you had close contact with who is under investigation or in quarantine for possible COVID‐19 infection? Close contact is defined as any individual who was within 6 feet of an infected person for at least 15 minutes. *

Yes

In the last three days have you had any of the following symptoms: *

Fever greater than 100.4° F

Chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea

Diarrhea

Vomiting

I have not and do not have any of the above symptoms

In the last 24 hours, have you taken fever-reducing or other symptom-altering medicines due to COVID or COVID like symptoms (e.g. ibuprofen, Tylenol, or cough suppressants)? *

Yes

Do you currently have COVID-19, or are you caring for someone who has COVID-19? *

Yes

By checking below I certify that the responses provided above are true and accurate to the best of my knowledge and participation in this event is voluntary. *

By checking below I certify that the responses provided above are true and accurate to the best of my knowledge and participation in this event is voluntary.

Required

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