Dixie Shootout - USAC.25 HEALTH SAFETY QUESTIONNAIRE

USAC.25 HEALTH SAFETY QUESTIONNAIRE for HQMA Region Race ON 6/25/2020

USAC .25 Driver / Handler / Spectator Name*

First Last

This form should be completed by anyone attending the event; club members, officials, competitors, family and friends.

Phone*

USAC .25 Track Affliation*

1.In the last 72 hours have you had a fever and/or taken medication for a fever?*

2. In the last 7 days have you had symptoms of a lower respiratory illness (cough, difficulty breathing, etc..)?*

3. In the past 14 days have you been in close contact with a person known/suspected to have COVID-19 and/or have you been diagnosed with COVID-19?*

Is the current Temperature 100.1 or higher for the person you are completing this health review?*

Date Health Assessment was completed*

MM

DD

YYYY

Enter the date you completed the health assessment.

Electronic Signature of Named person above or Parent/Guardian of Minor*

By typing your name, you agree the answers above are correct to the best of your knowledge.