COVID-19 Exposure Response Form
This form is intended for coaches, staff, parents & volunteers to report any COVID-19 exposure or risk of exposure to prevent spread of the virus during Clinton Boys and Girls Club (CBGC) activities.
STEP 1 -- If a staff member, coach or participant has answered "yes" to any of the below screening questions, then they should stay home for minimum 2 weeks. After the 2 week period, they should confirm a "yes" response no longer applies to the below questions before phasing back into CBGC hosted activities.
STEP 2 -- Reporting COVID-19 exposure in this form. IF a staff member or coach becomes aware of any staff member, coach or participant that has answered "yes", they should collaborate with that person/family to complete this COVID-19 Exposure Response Form to ensure proper steps have been taken to eliminate risk for future spread.
STEP 3 -- CBGC staff will follow up with reporting person, staff member or coach to confirm details and align on next steps.
STEP 4 -- Reporting person or CBGC Membership Director (with guidance) will communicate with the participant and/or participant's family on appropriate next steps.
Any staff member, coach or participant that has tested positive for COVID must have a doctor's note with a medical clearance in writing OR a negative COVID-19 test to return to CBGC activities.
Any staff member, coach or participant that has been in a high risk scenario but has not been tested or tested positive must undergo a 2-week symptom-free quarantine.
If you have any questions about COVID-19, CBGC protocols or this COVID-19 Exposure Response Form, please reach out to the Membership director or Parent Relations team for guidance. Thank you for your attention to this to support the safety of our Clinton community.
(If answer “yes” to any of the below questions, please have staff member, coach or participant stay home)
(1) Have you received a positive test result for COVID-19?
(2) Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing, loss of taste/smell)?
(3) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?
(4) Have you had close contact with or cared for someone who has experienced symptoms of COVID-19 within the last 14 days but has not been tested?
(5) Have you returned from international travel within the last 14 days?
(6) Have you been in close contact with anyone who has traveled internationally within the last 14 days?
Sign in to Google
to save your progress.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service