COVID-19 Daily Screening Questionnaire

COVID-19 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

Do you have a positive COVID-19 test?

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with:
* Anyone who is known to have laboratory-confirmed COVID-19?
* Anyone who has any symptoms consistent with COVID-19?

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

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) *

Month Day Year
Date
TIME STAMP (ADMIN) *

: Hour Minutes AM/PM Option
Should be Empty:

COVID-19 Screening Questionnaire