Troop 212 / COVID-19 Questionnaire
* Required
Participant Name (first and last)
*
Your answer
Contact Phone (xxx-xxx-xxxx)
*
Your answer
Contact E-Mali
*
Your answer
Event Name
Choose
Troop Meeting on April 6 2021
JLT / Skill-o-ree on April 10 2021
Troop Meeting on April 13 2021
Hut Shed Project / Patrol Boxes on April 18 2021
Advancement / Greenbar on April 20 2021
Troop Meeting on April 27 2021
In the last 48 hours, have you experienced any of the following symptoms? (Please check “yes” or “no.”) If “yes” is answered to any question the respondent may not attend the event.
*
Yes
No
Body temperature 100F or greater
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 or vomiting
Diarrhea
Within the last 10 days have you had a COVID test and not received results?
Do you live in the same household with, or have had close contact with someone who within the past 14 days has (1) been in isolation for COVID-19; or (2) tested positive for COVID-19?
Yes
No
Body temperature 100F or greater
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 or vomiting
Diarrhea
Within the last 10 days have you had a COVID test and not received results?
Do you live in the same household with, or have had close contact with someone who within the past 14 days has (1) been in isolation for COVID-19; or (2) tested positive for COVID-19?
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