BGCA East Aurora Health Questionnaire

The safety of our children, staff, and families remains the Boys & Girls Club of East Aurora’s overriding priority. As the coronavirus (COVID-19) outbreak continues to evolve and spread globally, we are closely monitoring the situation and will periodically update our practices and policies in accordance with what we deem required to keep our children and staff safe from exposure.

To prevent the spread of COVID-19 and reduce the potential risk of exposures to our children and staff, we are requiring an online screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this facility.

Device Time

Date Hour Minutes AM/PM Option

Name *

First (Given) Name Last Name (Surname)

Risk

Email *

(This sends the results to your email, enabling documentation.)

Have you received a confirmed diagnosis for COVID-19 by a COVID-19 test or from a diagnosis by a health care professional in the past 10 days? *

Yes No

Are you currently waiting on results of a Covid-19 test? *

Yes No

In the past 10 days, have you traveled internationally? *

Yes No

In the past 10 days, have you been in close contact with a person who is known to have a laboratory-confirmed Covid-19 diagnosis or with anyone who has symptoms consistent with Covid-19 for 10 minutes over a 24-hour period? *

Yes No

Have you been directed to quarantine or isolate for 10 days by the NYS DOH, School District or healthcare provider because you may have been exposed to a person with Covid-19? *

Yes No

Have you experienced any cold or flu-like symptoms in the past 72 hours to include: fever of 100.4 degrees Fahrenheit or higher, *sore throat, *cough, *difficulty breathing, new loss of taste or smell, new onset of severe headache, vomiting or diarrhea? *For people with chronic conditions, a positive answer should represent a change from their typical health status. *

Yes No

I certify all the information provided is shared to the best of my ability.

Note: If you answered NO to all questions, access to the Boys & Girls Club of East Aurora is approved for the current day. If you answered YES to ANY question, access is NOT approved. If you have any questions or need to discuss the circumstances surrounding your answer, please contact the Club at 652-4180 prior to attendance.