ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
Troop 171B and Troop 171G
2
COVID-19 Health Screening
3
Event:
4
Date:
5
Screener name:
6
7
Scout or Adult Name -->
8
Check-in Time
9
Current temperature
10
11
In the past 14 days have you tested positive for COVID-19, or been in contact with anyone suspected or confirmed to have COVID-19 (Yes or No)?
12
If you answer "Yes", you are not eligible to participate in today's activity. *** Self-isolate at home for 14 days following close contact with the COVID-19 positive person.***
13
14
In the past 24 hours, have you experienced ____ (Yes or No)?
15
Fever or chills
16
Shortness of breath or difficulty breathing
17
Fatigue
18
Muscle or body aches
19
Headache
20
Loss of taste or smell
21
Sore throat
22
Congestion or runny nose
23
Nausea or vomiting
24
Diarrhea
25
26
If you answer "Yes" to any of the symptoms listed above, or you temperature is 100.4 degrees Fahrenheit or higher, you are not eligible to participate in today's activity. *** Self-isolate at home and contact your primary care physician's office for direction.***
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100