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Visiting Team Covid Health Questionnaire

  1. Does your program have an active Covid screening process (ie. Healthcheck)?

Yes      No

  1. Have you, your staff or any of your players had COVID-19 within the last 14 days?

Yes      No

  1. In the last 14 days, have you, your staff or any of your players been in close contact with anyone you know: (a) who exhibited the symptoms of COVID-19, (b) who is/was being tested for COVID-19, (c) who has COVID-19, or (d) who was exposed to someone with COVID-19?

Yes      No

 

  1. Have you, your staff or any of your players had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish”, or had a temperature that is elevated for you or 100.4F or greater?

Yes      No

 

  1. In the last two weeks have you, your staff or any of your players traveled internationally or outside of New Jersey.

 Yes     No

  1. In the past 24 hours, have you, your staff or any of your players experienced the following unrelated to seasonal allergies:

       Fever                                       Yes      No                   Cough                                     Yes      No

       Loss of Taste                           Yes      No                   Loss of Smell                          Yes      No

       Aches and Pains                      Yes      No                   Sneezing                                  Yes      No

       Sore Throat                             Yes      No                   Other Covid Symptoms          Yes      No

Team Name:____________________________________________________________

Team Representative Name (please print):____________________________________

Signature of Team Representative:______________________________________ Date:

If you answered any of the questions (on behalf of yourself or your team) above in the affirmative, please contact the head coach of the team you are playing immediately to discuss the upcoming event.  Regardless of how you answer the questions provided in this survey, if you have symptoms consistent with COVID-19 or feel you may be developing symptoms consistent with COVID-19, you cannot attend or participate in any youth lacrosse activities and should contact a local healthcare professional.