Mad River Volunteer Health Screening

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Please review the COVID-19 health screening questions below carefully and select the appropriate checkbox based on whether you respond "No" or "Yes" to one or more of the questions. 1. Within the past 10 days, have you had close contact with anyone that has COVID-19? Contact is being 6 ft (2m) or closer for more than 15 minutes cumulatively in a 24 hr period, caring for them, or having direct contact with them or their body fluids (for example, kissing, being coughed or sneezed on, or sharing a drink or eating utensils)? *Volunteers who work in the healthcare field, are part of a mandatory respiratory protection program and wore an N95 at the time of close contact with a COVID-19 positive person can answer “no” to this question. 2. Are you currently under direction from public health or a medical professional to quarantine or isolate because of concerns of COVID-19? 3. Have you traveled internationally or domestically in the last 10 days public health requires a quarantine following travel? 4. Have you tested positive or were you diagnosed as presumed positive for COVID-19 within the past 10 days? 5. Do you have the following sign or symptom (not due to a known health condition): a fever (either a measured temperature of 100.4 F (38 C) or greater, OR feeling feverish, including having chills)? 6. Do you have the following sign or symptom (not due to a known health condition): a new or worsening cough? 7. Do you have the following sign or symptom (not due to a known health condition): shortness of breath or difficulty breathing worse than normal for you at altitude? 8. Do you have the following sign or symptom (not due to a known health condition): new loss of taste or smell? 9. Do you have the following sign or symptom (not due to a known health condition): sore throat? 10. Do you have the following sign or symptom (not due to a known health condition): muscle or body aches that are not normal for you with exercise or altitude? 11. Do you have the following sign or symptom (not due to a known health condition): vomiting or diarrhea? 12. Do you have the following sign or symptom (not due to a known health condition): runny nose or congestion that is not normal for you? 13. Do you have the following sign or symptom (not due to a known health condition): new or severe headache? 14. Do you have the following sign or symptom (not due to a known health condition): new fatigue that is not normal for you with exercise or altitude?

I can confirm "No" responses to all questions above and and pass the health screening. (Select one)

I understand I can continue to provide volunteer services as long as I can respond to "No" to every question.

I confirm that I am answering "Yes" to one or more of the questions above and therefore, do not pass the health screening and am excluded from volunteering for 10 days. (Select one)

I understand that I should follow public health guidelines to isolate or quarantine based on needing to answer "Yes" to one or more of the questions above. This means I will not be able to provide my volunteer services until I have completed required isolation or quarantine.

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