COVID Self-Certification Screening

Please fill in this form on the day you're planning to be in the buidling

If you answer yes to any of these questions, stay home you will not be permitted to enter the building

Swimmer Name

Do you have any of the following symptoms:

New fever, chills, muscle or body aches

New cough, sore throat or runny nose

New shortness of breath or difficulty breathing

New fatigue or headache
New loss of taste or smell
New nausea, vomitting or diarrhea

Have you been diagnosed with COVID-19 in the last 14 days?

Do you have close contact with someone who has been quarantined or confirmed with COVID-19 in the last 14 days?



Have you travelled outside of Illinois in the past 14 days, to any of the following places: Alabama, Arkansas, Georgia, Idaho, Iowa, Kansas, Minnesota, Mississippi, Missouri, Montana, Nebraska, North Dakota, Oklahoma, Puerto Rico, South Carolina, South Dakota, Tennessee, Utah, and Wisconsin









Is your temperature today above 100.4 degrees Fahrenheit?