Covid-19 Screening Questionnaire

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The safety of the employees, volunteers, participants and family members of the BARC Summer Programs is our overriding priority. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure, we are asking everyone to complete and submit this questionnaire prior to taking part at each session of our programs. You must complete this form at every session of our programs.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and others involved in our programs.






    1. Are you currently experiencing or have you experienced in the past 14 days, any of the following symptoms?
    Fever (100 degrees Fahrenheit/ 37.7 degrees Celsius or greater as measured by an oral thermometer)?
    YesNo


    Cough?
    YesNo


    Shortness of breath or difficulty breathing?
    YesNo


    Sore throat?
    YesNo


    New loss of taste or smell?
    YesNo


    Chills?
    YesNo


    Head or muscle aches?
    YesNo


    Nausea, diarrhea, vomiting?
    YesNo


    2. In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?
    YesNo


    3. In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?
    YesNo


    4. Have you been tested for COVID-19 and are waiting to receive test results?
    YesNo


    5. Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider's assessment or your symptoms?
    YesNo
    NOTE: If you have tested positive for COVID-19 or have been presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms, please contact the program coordinator when: (1) you have had no fever for at least 72 hours (3 full days), without the use of fever-reducing medications; (2) your other symptoms have improved; and at least 7 days have elapsed since your symptoms first appeared.


    6. In the past 14 days, have you been on a commercial flight or traveled outside of the United States?
    YesNo


    7. In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?
    YesNo


    8. Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by attending our program? If "yes", please provide a brief explanation.
    YesNo

    Explanation (if applicable):




    By checking the box below, you are providing your digital signature. Your IP address and user agent will be submitted with the form.
    Digital Signature


    Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to the program coordinator.

    IMPORTANT: After submitting the form, please keep the window open to show the attendance staff that you submitted the form and let them know if you have answered "Yes" to any of the questions. Thank you!