Fillable PRE-SEASON COVID-19 SCREENING

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PRE-SEASON COVID-19 SCREENING

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PRE-SEASON COVID-19 SCREENING
NWAC PRE-PARTICIPATION EXAMINATION COVID-19 ADDENDUM
To ensure the safety of all participants within the Northwest Athletic Conference (NWAC), all incoming and returning student-
athletes are required to complete the following screening prior to participation in any team related activities.
THIS FORM MUST BE COMPLETED BY A MEDICAL PROVIDER WITHIN ONE OR TWO WEEKS PRIOR TO ARRIVAL ON CAMPUS.
A COVID-19 TEST IS NOT REQUIRED, BUT MAY BE COMPLETED IF DETERMINED TO BE APPROPRIATE BY THE MEDICAL PROVIDER
STUDENT-ATHLETE INFORMATION
Name (Last, First MI):
Student ID#:
Date of Birth (MM/DD/YYYY):
Local Address:
Permanent Address:
Cell Phone:
Sex (circle one):
Male
Female
COVID-19 SCREENING
Please complete the following information to assess your risk of exposure and symptom experiences related to COVID-19.
QUESTION
YES
NO
Have you been diagnosed with COVID-19?
Do you have medical documentation to support your diagnosis and treatment of COVID-19?
Date of Diagnosis (MM/DD/YYYY):
Did hospitalization occur with diagnosis?
Physician Name/Contact Information:
Have you been in contact with anyone diagnosed with COVID-19 in the past 14 days?
Have you experienced any of the following symptoms in the last 14 days?
YES
NO
DATE OF LAST SYMPTOM EXPERIENCE
I certify that I have provided true and accurate information to the best of my knowledge.
Student-Athlete Signature: ______________________________________________________________ Date: ______________
MEDICAL PROVIDER EVALUATION
Cardiac History/Symptom Review
Normal
Abnormal
Respiratory History/Symptom Review
Normal
Abnormal
Is this individual at high risk for complications?
Yes
No
Has the individual been tested for COVID-19
Yes
No
Date Completed:
Additional Notes/Recommendations:
Do you recommend further COVID-19 or follow up testing (EKG/PFT)? No Yes
Student-athlete is:
Not cleared for participation until follow up complete
- OR - Cleared to return to participation in accordance with the institutions return to activity
Medical Provider Name
___________________________________________Medical Provider Phone: _____________________
Medical Provider Signature: ______________________________________________________________ Date: ______________
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ACKNOWLEDGEMENT
In the interest of health and public safety during the COVID-19 pandemic, I acknowledge that I have truthfully and accurately
disclosed the above information regarding my health status, including any symptoms and exposure to COVID-19 in order for
INSTITUTION to evaluate before allowing my return to campus. I further acknowledge that, if additional evaluation or
assessment is required and requested by the institution, I hereby consent and will cooperate.
In addition, if any of the symptoms mentioned above appear after I am allowed to return to campus, I agree to stay at home
and to immediately report my change in status to the proper medical authorities at the INSTITUTION and to complete a new
Assessment, Acknowledgement and Consent form for approval before returning to campus. At all times while on campus, I agree to
follow all safety protocols and social distancing guidelines established by INSTITUTION, the City of ___________, ____________
County, and the State ________.
Student--Athlete Signature: _____________________________________________ Date: _________________
Parent/Guardian Signature: _____________________________________________ Date: _________________
Signature may be that of a student or athlete over 18 years of age.
If under 18, this form must be signed by the Parent or Guardian.
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PRE-SEASON COVID-19 SCREENING

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Completed 4 February 2021

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