Tuckahoe | Phase 3 COVID 19 Daily Health Survey

Date*

Name

First Last

Are you exhibiting any symptoms related to COVID-19, i.e. fever, cough, sore throat, shortness of breath, chills, muscle pain, headache, new loss of taste or smell, fatigue, congestion or runny nose, nausea or vomiting, or diarrhea currently or in the past 14 days?

Have you had any person-to-person contact with someone who has exhibited COVID-19 symptoms or who has been diagnosed with COVID-19 in the last 14 days?

Have you been free of any fever for at least the past 72 hours (that is three full days of no fever without the use of medicine that reduces fevers); AND other symptoms have improved (for example, when cough or shortness of breath have improved); AND at least 10 days have passed since symptoms first appeared. (if previously diagnosed with COVID-19)?

I agree to abide by Tuckahoe Recreation Club rules on social distancing, handwashing, and face covering as well as all other club policies, related to COVID 19 as well as in general during the time I am on the club premises.

I have read, understand, and answered each question above truthfully and to the best of my knowledge. By typing my name below, I am executing this survey.