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Sample COVID-19 Screening Form

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Revision as of 14:19, 24 March 2021 by Judycole (talk | contribs) (2021-03-24 - Generalized form)

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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 Cyan 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 respiratory 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 will, for myself and my heirs, executors, administrators and assigns, hold harmless the North American Word Game Players Association, dba the North American SCRABBLE Players Association (NASPA), Hasbro, Inc., their respective subsidiaries, affiliates, officers, directors, employees, and agents, and all other persons, firms, corporations or other entities, known or unknown, liable or who might be claimed liable, from any and all claims, demands, damages, actions, causes of action, losses, injuries, and/or costs of expenses, of whatsoever nature, resulting from or relating to this event and my participation in this event, including, without limitation, travel to and from this event, 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 of every nature and kind whatsoever relating to this event and my participation in this event, and releases claims that are known and unknown, suspected and unsuspected.

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