COVID-19 Screening Form

COVID-19 Screening Form

Please complete this form for every individual attending this event. This form must be complete for EVERYONE in attendance, not just 4-H members.


Due to the COVID-19 pandemic, and in an attempt to minimize the spread of the virus, Texas A&M AgriLife Extension Service is required to screen all youth, staff, and visitors participating in a youth day or overnight event. In order to be granted access to events, all visitors must truthfully complete and submit the following:

By completing this form, I hereby affirm that I,…


—1. While at the event I will maintain a minimum of 6 feet of separation from any other individuals not within my household.

—2. I have not in the past 7 days exhibited any of the known symptoms of COVID-19, including:
▪ Cough
▪ Shortness of breath or difficulty breathing
▪ Chills
▪ Repeated shaking with chills
▪ Unexpected muscle pain
▪ Headache
▪ Sore throat
▪ Loss of taste or smell
▪ Diarrhea
▪ Running a fever (or measuring a temperature of 100.0 degrees Fahrenheit or more)

—3. In the past 14 days I have not been in contact with any person known to have contracted COVID-19.


Although not required, I understand it is recommended that I wear a cloth face covering (over the nose and mouth), or non-medical grade face masks, if available. I also understand that it is recommended that I follow the minimum standard health protocols issued by the Texas Department of State Health Services and cited by the Texas Governor in his Executive Orders related to the pandemic. Local policy may require mandatory use of face coverings.

I understand that the virus that causes COVID-19 can be spread to others by infected persons who have few or no symptoms. Even if an infected person is only mildly ill, the people they spread it to may become seriously ill or even die, especially if that person is 65 or older with pre-existing health conditions that place them at higher risk. Because of the hidden nature of this threat, everyone should rigorously follow the practices specified in the DSHS protocols, all of which facilitate a safe and measured reopening of Texas. The virus that causes COVID-19 is still circulating in our communities. We should continue to observe practices that protect everyone, including those who are most vulnerable.

I understand that AgriLife Extension cannot guarantee that I will not contract the virus, even when implementing screening protocols. I further understand that safety is a shared duty, COVID-19 is a shared risk, and all community members, including visitors, must take steps to promote health and safety. I acknowledge that I am assuming the risk that I may contract the virus by entering facilities, even when screening protocols and mitigation measures are implemented.

I understand that AgriLife Extension is required to have this attestation in order for me to attend events sponsored by them and I sign below to confirm the truth of the above.

COVID-19 Screening Form

E-Signature (Parent if under 18)(Required)


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