Sample COVID-19 Screening Form

Directors can use this form to screen tournament or club participants for COVID-19 risk.

To play under the Cyan Safety Level, participants must answer Yes to all questions.

Directors may wish to post a copy of the list of questions and/or ask participants to review the list before arrival.

Sample COVID-19 Screening Form

Which of the following conditions do you meet for playing under NASPA’s COVID-19 Safety rules?

☐	It has been at least two weeks since I completed a government-recommended course of vaccination against COVID-19.
☐	I do not have a probable or confirmed case of an infectious disease.
☐	I have not had a positive COVID-19 test result in the last 10 days.
☐	I have not recently developed any new or worsening symptoms of COVID-19, unrelated to known causes or pre-existing conditions, such as: fever or chills, cough, difficulty breathing, shortness of breath, sore throat, difficulty swallowing, runny nose, stuffy nose, decrease or loss of sense of taste or smell, pink eye, headache, nausea, vomiting, stomach pain, diarrhea, feeling unwell, feeling extremely tired, sore muscles.
☐	I am in compliance with all government guidance pertaining to my travel to and participation in this event.

In consideration of my participation in this sanctioned NASPA event, I hereby release and forever discharge, and hold harmless, for myself and my heirs, executors, administrators and assigns, the North American Word Game Players Association, d/b/a NASPA, its subsidiaries, affiliates, officers, directors, employees, and agents, and all other persons, firms, corporations or entities, known or unknown, alleged to be liable or who might be claimed liable, from any and all claims, demands, damages, actions, causes of action, losses, injuries, costs and/or expenses of whatever nature, resulting from or relating to this event and my participation in this event, including, but not limited to: transportation or travel to and from this event, lodging and meals, prizes, time spent at this event, the cancellation of this event, and any activities and entertainment associated with this event or any free time personal activities. It is understood and agreed that this is a full and final release of all claims, known and unknown, of every nature and kind whatsoever relating to this event, and my participation in this event.

Printed name:	_______________________
Signature:	_______________________
Date:	_______________________
Phone/Email:	_______________________

References

• https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html
• https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/holidays/small-gatherings.html