FSVBC-Covid 19 Symptom Screening Form
In accordance with guidelines from the Centers for Disease Control (CDC), the California Department of Public Health (CDPH) and the Yolo County Health Officer, symptom screening is required to reduce the spread of COVID-19.*
Your FSVBC Team
Today's Date: This is the date you actually practiced on site with FSVBC team.
Temperature Check: I have taken my temperature upon arrival and it is BELOW 100.4 Fahrenheit.
Are you currently experiencing any of the following NEW OR UNEXPECTED COVID-19 symptoms? (**seek medical care)
Temperature over 100.4
Shortness of breath
Muscle or body aches
NEW loss of taste or smell
Congestion or Runny nose
Nausea or vomiting
DIFFICULTY BREATHING **
PRESISTENT PAIN OR PRESSURE IN THE CHEST **
NEW CONFUSION **
INABILITY TO WAKE OR STAY AWAKE **
Are you currently taking any NEW medication (prescription or over-the counter) that might mask the symptoms of COVID-19 or symptoms of a respiratory illness?
Is anyone in your household, or someone you have come in close contact with, ill or presenting symptoms of COVID-19, diagnosed with COVID-19 or self quarantining/self isolating as ordered by a physician?
Are you able to practice with a mask today if you were requested to do so?
All indoor practices will require players to wear a mask, which will need to fully cover your nose and mouth, upon entry and exiting of the building and during the entire practice. Will you be wearing a mask today?
Have you washed your hands or used alcohol-based hand sanitizer on entry?
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Woodland Joint Unified School District.