Safety Screening Checklist

Panthers Protecting Panthers (P3). Please remember to wear a mask and follow guidelines for social distancing.

Name Name First Last
Marching Band Position
Email
Phone Phone - ### - ### ####
Date Date / MM / DD YYYY
In the past 48 hours have you had any of the COVID-19 symptoms listed below that are new or unusual for you?

In the past 48 hours have you had any of the COVID-19 symptoms listed below that are new or unusual for you? Fever (Temperature of 100.4F or higher) or chills Cough Shortness of breath/ Difficulty breathing Fatigue Muscle or body aches Headaches New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea I am experiencing no symptoms
Have you been in contact with anyone diagnosed with, or displaying symptoms of, COVID-19 within the last 14 days?

Have you been in contact with anyone diagnosed with, or displaying symptoms of, COVID-19 within the last 14 days? Yes No
Are you awaiting COVID-19 test results either because
a) you have symptoms and/or
b) because you had close exposure to a person who is positive?

Are you awaiting COVID-19 test results either because
a) you have symptoms and/or
b) because you had close exposure to a person who is positive? Yes No
Within the last 14 days have you tested positive for COVID-19?

Within the last 14 days have you tested positive for COVID-19? Yes No
By submitting this screening, I affirm and attest that all the information and answers to screening questions herein are complete, true, and correct to the best of my knowledge.

Draw or Type

*Questions and symptoms are based on the latest guidelines from the CDC and clinicians at Florida International University. I understand this is a legal representation of my signature. Clear

Full Name

*Questions and symptoms are based on the latest guidelines from the CDC and clinicians at Florida International University. I understand this is a legal representation of my signature.
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