Self-Screening Questionnaire - Guests

The purpose of the self-screening questionnaire is to help you make decisions about clearance to Converse affiliated events. This system is not intended for the diagnosis or treatment of disease or other conditions, including COVID-19. This system is intended only as a precautionary measure to ensure your safety and the safety of others during this pandemic.

Name:

Phone Number:

This will be used exclusively for contact tracing purposes.

Email Address:

Symptoms

Symptoms should be relatively new and unrelated to any other chronic medical condition.

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.) 

Contact

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

*Close proximity means being within six feet of a person diagnosed with COVID-19 for a total of 15 minutes within a 24 hour period regardless of having a mask.

Testing

Within the past 14 days, have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your healthcare provider’s assessment of your symptoms?

What was the date of testing:

If you have tested positive for COVID-19 within the last 14 days or have been presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms, you will not be allowed to come to Converse’s campus or attend a Converse athletic event.

Positive or Presumptively Positive:

Have you tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?