WEST XC POD 4: Pre-Workout Screen
This form must be completed no more than 2 hours prior to your scheduled training session by all coaches, student-athletes, and staff. Each student-athlete is to complete this survey with their parent/guardian. Any athletes, coaches, or staff who believes they may be sick should remain at home. If you have a temperature of 100.4°F or have answered yes to any of these questions below, you should not attend any training sessions.
Email address *
Student-Athlete Name: by recording my name below, I acknowledge that i have reviewed the DASD Athletic Health and Safety plan and agree to all protocol as outlined in the plan. *
Parent/Guardian Name: by recording my name below, I acknowledge that i have reviewed the DASD Athletic Health and Safety plan and agree to all protocol as outlined in the plan. *
Please record temperature of student-athlete. *
In the past 72 hours, have you or anyone in your household experienced symptoms of acute respiratory illness, such as: a fever of 100.4°F or higher, fatigue, body aches, cough, shortness of breath, sore throat, runny/stuffy nose, chills? *
In the past 14 days, have you had close contact (i.e. within 6 feet for more than a few minutes) with anyone who tested positive for COVID-19 (AKA coronavirus), is in the process of being tested for COVID-19, is isolating as a result of a suspected COVID-19 infection, or is experiencing acute symptoms of COVID-19? *
I hereby state that I have answered these questions honestly and to the best of my ability as of today's date and time. I understand that if I answered yes to any of the questions above, I can not attend workouts until I have been contacted by a coach/athletic trainer or school administrator. Type your initials in the box below to certify your response. *
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