Safe Return to Footy: Self-Assessment Health Screen
In the interest of safety during the COVID-19 pandemic, you must answer the following questions BEFORE participating in a pod training session:
Name *
Email Address *
Cell Number *
1. Within the last 14 days, have you tested positive for COVID-19? *
2. Are you experiencing any of the following COVID-19 symptoms? *
Yes
No
Fever (≥ 100.4°F)
Cough or shortness of breath
Sore Throat
Chills
Muscle aches or rigors
Headache
New loss of taste or smell
Abdominal pain, nausea, vomiting or diarrhea
3. Within the last 14 days have you exhibited any of the symptoms noted in question 2? *
4. Within the last 14 days have you come in close contact (within approx. 6 feet) with anyone who, at the time of the contact, was exhibiting any of the symptoms noted in question 2? (If you are a Medical Professional, wearing appropriate PPE and following correct protocol at the time of contact, you may answer No.) *
5. Within the last 14 days, have you been in close contact with someone who, at the time of the contact, had a laboratory confirmed or presumptive COVID-19 diagnosis? (If you are a Medical Professional, wearing appropriate PPE and following correct protocol at the time of contact, you may answer No.) *
6. Have you traveled from another US state in the last 10 days? (travel between the contiguous states PA, NJ, CT, MA, and VT is permitted) *
If you answered yes to question 6, do you have a negative test results from at least 4 days after you returned to New York? Please bring evidence of negative results to training. *
7. Have you traveled Internationally within the last 10 days? *
*If you have answered YES to any of the above questions, DO NOT PARTICIPATE in club training sessions for the safety of your teammates! Please STAY AT HOME! (unless you have negative test results - please bring evidence to training)
ATTESTATION: By signing below, I affirm and attest to the accuracy of the above. I understand and agree that I may be asked to provide similar or additional attestations in the future. *
Today's date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy