Student-Athlete COVID-19 Screening

Please complete this form to help us assess your potential exposure/possession of COVID-19 and other illnesses.

Name*

First Name

Last Name

Central College ID Number*

Date of Birth*

Cell Phone*

Hometown*

City

State

Are You Currently Free From Illness?*

Yes No

Fever — Length of Symptom and Explanation*

Body Chills — Length of Symptom and Explanation*

Extreme Level of Fatigue — Length of Symptom and Explanation*

Cough — Length of Symptom and Explanation*

Pain/Difficulty Breathing — Length of Symptom and Explanation*

Shortness of Breath — Length of Symptom and Explanation*

Sore Throat — Length of Symptom and Explanation*

Body/Muscle Aches — Length of Symptom and Explanation*

Loss of Taste — Length of Symptom and Explanation*

Loss of Smell — Length of Symptom and Explanation*

Eye Discharge — Length of Symptom and Explanation*

Changes to Vision — Length of Symptom and Explanation*

Have You Had Any Direct Contact With Anyone Who Lives In or Has Visited a Place Where COVID-19 Is Spreading and/or Is In an Area Reporting an Increased Number of COVID-19 Cases (i.e. “Hot Spots”)?*

Yes No Unsure

Have You Had Any Direct Contact With Someone That Has a Suspected or Lab Confirmed Case of COVID-19?*

Yes No Unsure

During Your Time Away From Central College, Did You Self-Quarantine Due to Suspected Symptoms or Exposure to COVID-19?*

Yes No

During Your Time Away From Central College, Have You Been Living In, or Visited an Area Reporting an Increased Number of COVID-19 Cases?*

Yes No

Have You Been Diagnosed With COVID-19?*

Yes No

Date of Diagnosis:*

Do You Have Medical Documentation to Support Your Diagnosis and Treatment of COVID-19? *

Yes No

Physician Name*

Physician Location*

Please List ALL Countries, States, and Cities You Have Traveled to Since March 15, 2020, and the Dates You Were There:*

By signing below, I do hereby certify that all the above information is true to the best of my knowledge.

Student-Athlete Signature*

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Use your mouse or finger to draw your signature above

Parent/Legal Guardian (Athlete is Under 18)*

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Use your mouse or finger to draw your signature above

Age in Years