COVID-19 Participant Screening Tool Updated 5.7.2021
This form can be completed for each child and adult participant, or the questions can simply be used as a guide to complete the
Participant Screening Log for multiple participants at recurring activities, such as troop meetings. All COVID-19-related documen-
tation, such as this tool, should be securely retained for a minimum of 90 days after the Girl Scout activity for which they were
completed.
Name of participant: � Child � Adult
Name of parent/caregiver of participating child, if applicable:
Meeting/Activity: Date and Time: Location:
YES NO
� � 1. Have you (for participating adults)/your child (for parents/caregivers of participating children) had a
fever of 100.4˚F or greater within the last 24 hours (the 24 hours with no fever should be without the use
of fever-reducing medications)?
� � 2. Have you (for participating adults)/your child (for parents/caregivers of participating children) had any one or
a combination of symptoms of COVID-19 within the last 72 hours? Possible symptoms include cough, shortness
of breath or difculty breathing, chills, fatigue, muscle aches or pain, headache, new loss of taste or smell, sore
throat, congestion or runny nose, nausea or vomiting, diarrhea.
� � 3. Have you (for participating adults)/your child (for parents/caregivers of participating children) been tested for
COVID-19 due to suspicion of infection and not yet received a negative test result?
� � 4. If you (for participating adults)/your child (for parents/caregivers of participating children) previously
tested positive for COVID-19, do any of the below apply?
• If the participant had symptoms, it has not yet been 10 days since symptoms rst appeared
• If the participant did not have symptoms, it has not yet been 10 days since the participant received their
most recent positive test result
• The participant has had a fever of 100.4˚F or greater within the last 24 hours (the 24 hours with no fever
should be without the use of fever-reducing medications)
• Any other symptoms have not improved (with the exception of loss of taste or smell, which may persist
for weeks or months after recovery)
• The participant’s healthcare provider recommended testing to determine if the participant can resume
being around others but test results are still pending
� �
� �
5. During the past 10 days, have you (for participating adults)/your child (for parents/ caregivers of
participating children) been advised to self-isolate or quarantine by a doctor or health authority?
6. During the past 10 days, have you (for participating adults)/your child (for parents/caregivers of participating
children) been in contact with a person who has tested positive for, or is suspected to have had, COVID-19 in
the
previous 10 days?*
If the answer to any of questions 1-6 is YES, the participant is not permitted to attend any Girl Scout meeting or activity. By signing
below, I conrm that I have answered NO to questions 1-6 above for myself/my child as a participant in a Girl Scout activity.
Signature of p
articipating adult or parent/caregiver of participating child:
Date:
*Healthcare personnel (HCP) who had contact with a person who has tested positive for or exhibited symptoms of COVID-19 but who are able to continue working
and were following protocols (including wearing a respirator or facemask, eye protection, and all recommended PPE) may attend Girl Scout meetings and activities
as long as they meet all other participation parameters. Please refer to this link for the CDC’s definition of HCP.
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