COVID-19 Daily Screening Questionnaire

Please complete and submit the questionnaire

60 MINUTES PRIOR TO EACH TRAINING SESSION

Athlete Name *

First Name Last Name

Team Cohort *

Please respond Yes or No to each question *

Yes

No

Have you had a positive COVID-19 test within the last 14 days?

Within the past 10 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes in 24 hours) with:
* Anyone who is known to have laboratory-confirmed COVID-19?
* Anyone who has any symptoms consistent with COVID-19?

Have you been requested to isolate or quarantine by any organization?

Are you currently excluded from school?

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or because you may be sick with COVID-19?

Have you experienced any of the following COVID-19 symptoms in the past 48 hours?
* fever or 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

Have you traveled outside the U.S. within the past 7 days?

Guardian Name

First Name Last Name

Email

example@example.com

I certify to the best of my knowledge; this information is accurate.

Signature *

Clear

Questions: Contact the DPST COVID Team at 775-832-1176 / dpstadmin@dpsef.org

DATE (DAMIN) *

Date

TIME STAMP (ADMIN) *

: Hour Minutes AM/PM Option

COVID-19 Screening Questionnaire