Girl Scouts – North Carolina Coastal Pines
Volunteer and Member Self-Screening Checklist
The following is provided for volunteers’ and members’ personal use to document their self-screening process to
ensure they are able to go into the meeting or group activity planned for that day. Do NOT bring the completed
checklist to the meeting or activity. Prior to leaving home, please review the questions below. If the answer to any of
these questions is YES, please stay home and contact your meeting or group activity coordinator to cancel your in-
person attendance. Plan to attend virtually if that option is available.
Screening Questions
1.
Do you have a fever or above-normal temperature?
YES ___
NO ___
(fever is greater than100.4 degrees Fahrenheit)
2.
Have you had a fever in the past 48 hours (>100.4 degrees Fahrenheit)?
YES ___
NO ___
3.
Are you experiencing shortness of breath or having trouble breathing?
YES ___
NO ___
4.
Do you have a dry cough? YES ___ NO ___
5.
Do you have a runny nose? YES ___ NO ___
6.
Do you have a sore throat? YES ___ NO ___
7.
Have you recently lost or had a reduction in your sense of smell or taste? YES ___ NO ___
8.
Do you have any other flu-like symptoms, such as gastrointestinal upset, diarrhea
vomiting, headache, muscle pain or fatigue? YES ___ NO ___
9.
Do you have chills or repeated shaking with chills? YES ___ NO ___
10.
Do any members of your household have a fever or any of the symptoms described
above? YES ___ NO ___
11.
Have you or any member of your household been told to quarantine/isolate by a
healthcare provider or the NC Health Dept or other governmental agency? YES ___ NO ___
12. If you have been tested for COVID-19 and the test results were positive, do you
still have symptoms? YES ___ NO ___
(If your test result was positive, do not attend the event until at least 14 days after the symptoms have subsided.)
12.
If you have been tested for COVID-19 and are awaiting the test results, have you had
any of the symptoms described above in the past 14 days? YES ___ NO ___
13.
In the last 14 days, have you been in contact with someone who has
tested positive or who has been diagnosed as having COVID-19? YES ___ NO ___
14.
In the last 14 days, have you traveled to any foreign country?* YES ___ NO ___
If YES, where? _________________
15.
In the last 14 days, have you traveled out of state?* YES ___ NO ___
If YES, where? _________________
If any of these answers are YES, contact your troop leader or the event coordinator to cancel your in-person attendance
and plan to attend virtually if that option is available. *If “yes” on #14 or #15, please check latest travel guidance to
see if travel to a specific area guides you to refrain from participation in in-person activities.
If you or a member of your household tests positive for COVID-19 OR if you or a member of your household have been
told by a medical authority to self-isolate following attendance at an in-person Girl Scout meeting or event, please
contact Covidreporting@nccoastalpines.org and follow your local public health department instructions regarding
quarantine. We will maintain the confidentiality of your information. We will inform the others who attended the
meeting or event of their possible exposure to COVID-19.
