Bryst FA | COVID 19 Symptoms Checklist – LevelUp Marketing Solutions

All players, coaches and staff must complete this questionnaire prior to each training session.

Name*
Email*
1. Have you experienced any of the following symptoms in the last 14 days?
a. Fever (greater than 38.0 C)?*
- Yes
- No
b. Cough?*
- Yes
- No
c. Shortness of breath / difficulty breathing?*
- Yes
- No
d. Sore throat?*
- Yes
- No
e. Runny nose?*
- Yes
- No
2. Has anyone in your household experienced any of the above symptoms in the last 14 days?*
- Yes
- No
3. Have you, or anyone in your household travelled outside of Canada in the last 14 days?*
- Yes
- No
4. Have you, or anyone in your household been in contact in the last 14 days with someone who is being investigated as a suspected case of COVID-19?*
- Yes
- No
5. Are you currently being investigated as a suspected case of COVID- 19?*
- Yes
- No
6. Have you tested positive for COVID-19 within the last 10 days?*
- Yes
- No
If an individual answered “YES” to any of the above questions, they are not permitted to participate in any in-person soccer activity for a minimum of 14 days.