2021 Health Check-in for Troop 41
The Troop leadership must review each youth and adult participant's current health status, both before departure and upon arrival at the event. Anyone entering a Troop activity – including parents, siblings, visitors, etc. – must be screened.
TODAY'S DATE = DATE OF EVENT *
PARTICIPANT'S FULL NAME *
CONDITIONS *
ALL answers must be marked "NO" for the participant to attend.
YES
NO
Have you or has anyone in your household been in close contact* in the past 14 days with anyone known or suspected to have COVID-19 or is otherwise sick?
Have you or has anyone in your household been in close contact* with anyone who has been tested for COVID-19 and is waiting for results?
Have you or has anyone in your household been sick in the past 14 days, or have you or they been tested for any illness and are waiting for results?
Has anyone in your household been exposed to an individual known or suspected to have COVID-19 in the past 14 days?
Have you or has anyone you have been in close contact* with traveled on a cruise ship or internationally or to an area with a known communicable disease outbreak in the past 14 days?
*According to the Centers for Disease Control and Prevention (CDC), “close contact” means:
• You were within 6 feet of someone who has COVID-19 for a cumulative total of 15 minutes or more over a 24-hour period
• You had direct physical contact with an infected person (hugged or kissed them)
• You shared eating or drinking utensils
• An infected person sneezed, coughed, or otherwise got respiratory droplets on you
SYMPTOMS *
If anyone in your household has any one of the following new or worsening signs or symptoms of possible COVID-19 shown below, no one from the household should attend. ALL answers must be marked "NO" for the participant to attend.
YES
NO
Shortness of breath
Cough
Temperature 100.0 F or greater
Flu-like symptoms
Repeated shaking with chills
Fatigue
Muscle or body aches
Headache
Sore throat
Loss of taste or smell
Diarrhea
Nausea or vomiting
*Potential Higher-Risk Individuals* *
If the answer is “yes” below, the Boy Scouts of America recommends that persons who are in a higher-risk category as defined by the CDC guidelines should not attend scouting events in person and stay home. I understand that should I choose to participate in person, I must have approval from my health care provider and exhibit none of the conditions or symptoms above.
YES
NO
Are you in a higher-risk category as defined by the CDC guidelines, including older adults, people with medical conditions, and those with other individual circumstances?
ASSUMPTION OF RISK *
Required
CONTACT TRACING *
Required
RELEASE AND WAIVER *
Required
ELECTRONIC SIGNATURE (Adult Participant or Parent of Participants under 18) *
Type your NAME followed by the DATE as your signature below. e.g. Webmaster 3/1/21
Submit
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