EACH USAC.25 MEMBER (Drivers & Handlers)
MUST COMPLETE THEIR OWN FORM
Team Name
USAC.25 SAFETY QUESTIONNAIRE
The safety of our drivers, competitors and USAC.25 members remain a priority. To prevent the spread of COVID-19 and reduce the potential risk of exposure to club members, officials and competitors, please complete this simple health screening questionnaire.
USAC.25 Member Name
*
First Name
Last Name
USAC.25 Member Phone Number
*
-
Area Code
Phone Number
USAC.25 Home Club/Track
*
Event Attending
:
In the last 72 hours have you had a fever and/or taken medication for a fever?
*
YES
NO
In the last 7 days have you had symptoms of a lower respiratory illness (cough, difficulty breathing, etc..)?
*
Yes
No
In the past 14 days have you been in close contact with a person known/suspected to have COVID-19 and/or have you been diagnosed with COVID-19?
*
Yes
No
Current Temperature:
*
Is your current temperature 100.1 or higher?
*
Yes
No
Signature
Register
Should be Empty: