SMASH Daily Health Self-Report Form
Must be completed the same day you or your athlete attend any SMASH activity
SMASH participant's Full Name
SMASH participant's Date of Birth
Today, or in the past 24 hours, have you/your athlete, or any member of your/the athlete's household had any of the following symptoms or fits the description: (If you answer Yes to any of the checkboxes you should stay home and not attend today's SMASH session.)
Fever, shortness of breath or difficulty breathing, cough, chills, sore throat, new loss of taste or smell
Returned from travel outside of MA and not yet received a negative test result or is in the 14 day quarantine period (excluding the designated low risk states NH, ME, VT, CT, NY, NJ, CO, DE, PA, WV)
Is awaiting the result of a COVID-19 test, or has been identified as a close contact of someone with a positive COVID-19 test and has not yet completed the 14 day quarantine, regardless of the test result
Lives in Rhode Island
No to all of the above
By typing my name below I attest that the above information is accurate to the best of my knowledge for the participant named above:
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