COVID-19 Health Screening Questionnaire for eSports Areana Visitors
COVID-19 Health Screening Questionnaire for eSports Areana Visitors
Name
Name
*
First
Last
Email
*
Please let us know if you have had any of the following:
Do you feel ill now, and if so, are you feeling any of these symptoms:
• Fever of 100.4°F or greater
• Chills
• New cough
• Sore throat
• Headache
• Runng of stuffy nose
• Shortness of breath
• Vomiting
• Diarrhea
• Skin rash
• Loss of taste or smell
• Tiredness/fatigue
• Muscle ache
• Chest pain or pressure
Have you taken medicine to bring down a fever of 100.4°F or more? (E.g., Tylenol or ibuprofen)
Are you subject to the state’s mandatory (full) 14-day quarantine due to travel or otherwise? Note: this does not include modified quarantine procedures for university students and accompanying parents/family members.
Have you had contact with anyone whose lab test confirmed COVID-19 within 14 days of symptom onset?
Are you awaiting the results of a COVID-19 lab test that was ordered by a physician in response to your symptoms?
Is a member of your household awaiting the results of a COVID-19 lab test that was ordered by a physician in response to the household member’s symptoms?
Answer
*
Answer
I certify that the answers to all of the above questions are "No" and I will enter the eSports Areana
I certify that one of the answers to the above questions is "Yes" I will not enter any HPU premises/buildings.
Today's Date
Today's Date
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MM
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YYYY
If you have any of the above symptoms or exposures, we ask that you
DO NOT enter the HPU premises/buildings at this time.