TI Health Screening Form

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First Name *

Last Name *

In the last 14 days has anyone in your household been in contact with someone who has tested positive for COVID-19? *

Yes

In the last 48 hours have you experienced any of the following symptoms? *

Fever of 100.0 or greater

Fatigue, muscle, or body aches

Runny nose, or congestion

Dry Cough

Sore Throat

Nausea, vomiting, or diarrhea

Loss of taste or smell

Shortness of breath

No symptoms

Required

In the last 10 days has anyone in your household spent more than 24 hours in a state which does not share a border with New York State? *

Yes

Are you a _________________? *

Home Team Parent

Away Team Parent

Official

Chaperone

Other:

Athlete you are here for ________________________. *

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