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Volunteer
Volunteer Health Screening
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Name
*
First
Last
I am filling this form out for our whole family and all answers represent the names below
YES
Names of people in my family
Date
*
Instructions
ALL VOLUNTEERS must be asked the following below, within 24 hours of coming to camp. This record will be kept for 14 days from completion of this form and this form is available upon request from the Public Health Department.
1 - Do you have any of the following respiratory symptoms which are new or unusual for you?
*
Fever
New or worsening cough
New or worsening shortness of breath
None of the above
If YES to any, you will not be allowed to come to Camp Chinquapin at this time. - If NO to all, proceed to remaining questions
2 - Volunteer's Temperature
*
3 - Do you have a fever (temperature 100.4°F or greater)
*
Yes
No
If YES, you will not be allowed to come to Camp Chinquapin at this time. - If NO, proceed to question 4.
4 - 1 - Are you feeling feverish?
*
Yes
No
4 - 2 - Are you having chills?
*
Yes
No
If YES to any, you will not be allowed to come to Camp Chinquapin at this time. If NO, proceed to question 5.
5 - In the last 14 days have you been exposed to any persons with confirmed COVID-19 by lab test?
*
Yes
No
If YES, you will not be allowed to come to Camp Chinquapin at this time. If NO, we look forward to seeing you soon.
Person performing screening
*
Relationship to Volunteer being screened
If you are doing this screening for someone other than yourself, please note above
Phone
Submit
