Colchester Legion Stadium - Covid 19 Screening Form          

Do you have any of the following new or worsening symptoms or signs?              

              New/Worsening cough                                                           Yes        No

              Shortness of breath                                                                 Yes        No

              Sore throat                                                                                Yes        No

              Runny nose/ sneezing nasal congestion                               Yes        No

              Loss of sense of smell or taste                                               Yes        No

              Nausea/vomiting                                                                      Yes        No

              Chills or sweats                                                                         Yes        No

Have you returned from travel outside of the Atlantic Bubble in the last 14 days?    Yes        No        

Have you come into close contact with anyone who travelled outside of the Atlantic Bubble in the last 14 days?                                                     Yes        No             

Do you have a fever?                   Yes        No                       

Have you had close contact with anyone with a respiratory illness or confirmed or probable case of Covid 19?                                           Yes        No             

Name (Please print): _____________________________________________________

Signature: (Parent or Guardian if under 18) ___________________________________

Date: _________________________________________________________________