USAC.25 HEALTH SAFETY QUESTIONNAIRE

USAC.25 HEALTH SAFETY QUESTIONNAIRE for HQMA Region Race ON 6/25/2020
The safety of our drivers, competitors and USAC.25 members remain a priority. To prevent the spread of COVID-19 and reduce the potential risk of exposure to club members, officials and competitors, please complete this simple health screening questionnaire.
REQUIRED FOR EVERYONE ATTENDING THE EVENT
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?*
- YES
- NO
2. In the last 7 days have you had symptoms of a lower respiratory illness (cough, difficulty breathing, etc..)?*
- YES
- NO
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?*
- YES
- NO
Is the current Temperature 100.1 or higher for the person you are completing this health review?*
- YES
- NO
Date Health Assessment was completed*
Month
Day
Year

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.

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