Player COVID-19 Self Screening Questionnaire

Player COVID-19 Self Screening Questionnaire
Midlands Schoolboys/girls ETP Covid-19 Self Assessment Declaration 20/21
Should you answer "YES" to any of the below questions your child should NOT attend the ETP Training sessions and before they return, should follow appropriate medical advice and guidelines
1) Have you had any of the following symptoms in the last 24 hours?
Rows Yes No
Cough
Shortness of breath of difficulty breathing
OR at least TWO of the following symptoms in the last 24 hours:
Rows Yes No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
If you answered “Yes” to question one, please DO NOT attend this weeks ETP session. You should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
2) In the last 14 days have you:
Rows Yes No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise
If you answered “Yes” to any part of question two, please DO NOT attend this weeks training sessions. You should self quarantine for at least 14 days.
I certify to the best of my knowledge; this information is accurate.
Parents Name
First NameLast Name
Childs Name
First NameLast Name
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

Rows	Yes	No
Cough
Shortness of breath of difficulty breathing