COVID-19 Health Screening Volunteer Form

This form is to be completed each day by all volunteers, independent contractors, or staff of My G.I.R.L.S., Inc.

Name

Date Completed

Reason for Attending

Coaching

Volunteering

Other

You must answer the following questions before working/volunteering for or on behalf of M G.I.R.L.S., Inc. every day that you work/volunteer.

If any answers change, notify another staff/volunteer and immediately leave.

In the last 10 days, have you been diagnosed with COVID-19 or had a test confirming you have the virus?

Yes

In the past 14 days, have you had “Close Contact”* with someone who was diagnosed with COVID-19 of had a test confirming they have the virus while they were contagious. Close Contact” means you had any of the following types of contact with the person with COVID-19 (regardless of whether you or the person with COVID-19 were masked) while they were contagious**”• Were within 6 feet of them for a total of 15 minutes or more in a 24 hour period• Lived or stayed overnight with them• Were their intimate sex partner, including only kissing• Took care of them or they took care of you• Had direct contact with their body fluids or secretions (e.g., they coughed or sneezed on you or you shared eating or drinking utensils with them). Contagious Period: People with COVID-19 are considered contagious starting 48 hours before their symptoms began until 1) at least 10 days have passed since their symptoms began, 2) they haven’t had a fever for at least 24 hours AND 3) their symptoms have improved.If the person with COVID-19 never had symptoms, they are considered contagious starting 48 hours before their positive COVID-19 test was collected until 10 days after they were tested

Yes

In the past 24 hours, including today, have you had one or more of these symptoms that is new or not explained by another condition? • Fever (100.4⁰F/38⁰C or greater), chills, repeated shaking/shivering• Cough• Sore throat• Shortness of breath, difficulty breathing• Feeling unusually weak or fatigued• Loss of taste or smell• Muscle or body aches• Headache• Runny or congested nose• Diarrhea• Nausea or vomiting

Yes

I understand that if I answered “YES” to ANY of these questions, I may not be in attendance and must proceed as follows:
If you answered YES to QUESTION 1 or QUESTION 2 in accordance with the Health department’s directive, you must isolate or quarantine accordingly. If you answered YES to QUESTION 3, you may have COVID-19 and to keep others safe, you should isolate until you know whether you have COVID-19, you may want to get tested!