BlackDog Swimming Health Screening Questionnaire
This form follows the MDH guidelines for contact tracing and daily symptom tracking. This form is REQUIRED to be completed by a parent of each athlete before arriving for practice at both Burnsville High School and Eagle Ridge Junior High during the winter 2020-2021 season.
All information collected is only to be used for notification and contact tracing as required by the MDH and the CDC. No personal information will be shared outside the coaching staff and the COVID liaison.
EmmaSwimmer's First Name
Swimmer's Last Name
Which group does your swimmer belong to?
Has the swimmer had a fever of 100.4 or higher in the last 24 hours?
Has the swimmer or any immediate family member experienced any of the following symptoms in the last 24 hours?
Shortness of breath
Body / muscle aches
loss of taste or smell
abdominal pain / dirreahea
none of the above
Has the Swimmer been in contact with someone who has exhibited COVID-19 symtoms or that has tested positive for COVID-19 in the last 7 days? (contact is defined as being closer than 6 feet for 15 minutes or more)
Has the swimmer been asked to quarantine for any reason related to COVID-19 in the last 14 days by an organization? (school, club, doctor, MDH, other)
Do you agree to immediately contact the coaches at BlackDog if there are any changes to your swimmer's health or if they or an immediate family member have a potential COVID-19 exposure.
Do you have any additional comments or concerns?
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