Troop 212 / COVID-19 Questionnaire
Participant Name (first and last) *
Contact Phone (xxx-xxx-xxxx) *
Contact E-Mali *
Event Name
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?
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