COVID-19 SCREENING QUESTIONNAIRE
Today's Date
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Month
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Day
Year
Date
Sport
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Football
Men's Basketball
Women's Basketball
Volleyball
Softball
Cheer
Athlete Name
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First Name
Middle Name
Last Name
DOB
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Month
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Day
Year
Date
Sex
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Male
Female
Athletes Temperature Today (F)
Date of Departure from TVCC Campus
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Month
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Day
Year
Date
Date of Arrival to TVCC Campus
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Month
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Day
Year
Date
Type of Check In
INITIAL
Subsequent
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Please list ALL Cities, States you have traveled to with the last 24 hours
Lodging accommodations during time of travel in the last 24 hours (Check all that apply)
House or Apartment
Hotel
Dormitory
Other
Other Accommodation in the last 24 hours
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Please list ALL Cities, States, AND Countries you have traveled to with the last 30 days
Lodging accommodations during time of travel (Check all that apply)
House or Apartment
Hotel
Dormitory
Other
Other Accommodation
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Symptoms History
Have you had any of the following symptoms in the past 14 days:
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Fever
Cough
Loss of Taste or Smell
Chills
Repeated shaking with chills
Headache
Sore Throat
Weakness
Muscle Pain
Diarrhea
Shortness of Breath or difficulty breathing
NONE of these symptoms
When did your symptom(s) begin:
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Month
/
Day
Year
Date
Have these symptoms resolved:
NO
YES
Have you been in direct contact with anyone who reported any above symptoms?
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NO
YES
Have you been in direct contact with anyone who had a confirmed or presumed positive test for COVID-19?
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NO
YES
Have you been tested for COVID-19?
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NO
YES
Date of Test:
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Month
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Day
Year
Date
If YES to being tested, were you told to self-quarantine or self-isolate?
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NO
YES
If YES to being told to self-quarantine or self-isolate, DID YOU?
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NO
YES
Have you been diagnosed with COVID-19?
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NO
YES
Date of Diagnosis:
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Month
/
Day
Year
Date
If YES to being diagnosed, were you told to self-quarentine or self-isolate?
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NO
YES
If YES to being told to self-quarantine or self-isolate, DID YOU?
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NO
YES
If YOU HAVE BEEN DIAGNOSED with COVID-19, was recovery confirmed by 2 negative tests or symptoms resolution (Specify)
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NO
YES
Recovery Specifications:
0/100
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Current Medications
List all medication you are currently taking, including over the counter medications
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Affirmation
I affirm that the answers I have provided above are truthful and accurate. I understand that any misrepresentation or omission of facts may result in expulsion from TVCC Athletics and may result in legal consequences.
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I Agree
Athlete's Signature
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