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PROTOCAL FOR PRE-TRIP SCREENING FOR HIGH RISK INDIVIDUALS AND PARTY TRAVELING TOGETHER.
Update: May 2022

It is recommended by the State Parks & Wildlife, Forest Service, BLM that people at higher risk for severe illness from COVID-19 SHOULD NOT GO on backcountry trips. High risk individuals include, but are not limited to people with the following conditions:

  • 65+ years of age with questionable health issues.
  • Chronic lung disease or moderate to severe asthma Dec. 2022
  • Severely obese
  • Diabetes, chronic kidney disease, or undergoing dialysis
  • Liver disease
  • Cardiovascular disease
  • Other immunocompromised individuals (HIV, undergoing cancer treatment, or other underlying medical conditions)

This questionnaire is a possible screening for guests while on a backcountry trip:  We may check guests for symptoms of CV19 (as outlined previously in this document) including measuring temperatures for fever (100.4°F/38°C or higher) or chills.   Remind guests to report any illness they may develop prior to or during their trip to the trip leader immediately, especially if sick with fever, cough, muscle aches and pains, sudden changes in smell or taste, sore throat, and/or shortness of breath.

 

COVID 19 SCREENING DVORAK EXPEDITIONS - PRE-TRIP QUESTIONNAIRE

Before Arrival, each guest is requested to fill out an online questionnaire (or scanned and emailed version) 7-14 days before arrival, this questionnaire will be developed with the following questions:

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
DVORAK EXPEDITIONS - PRE-TRIP QUESTIONNAIRE Before Arrival, each guest is requested to fill out an online questionnaire (or scanned and emailed version) 7-14 days before arrival, this questionnaire will be developed with the following questions:

1.  Have you recently experienced any of the following symptoms?  

Fever (100.4°F/38°C or higher) or chills?*
No
Yes
Cough that you cannot attribute to another health condition.*
No
Yes
Shortness of breath or difficulty breathing that you cannot attribute to another health condition?*
No
Yes
Sore throat that you cannot attribute to another health condition?*
No
Yes
Muscle aches that you cannot attribute to another health condition, or that may have been caused by a specific activity (such as physical exercise)*
No
Yes
Loss of taste or smell?*
No
Yes

2. Have you been in contact with an individual who has been ill with flu-like symptoms in the last 14 days? *

3. Have you been diagnosed with COVID-19 in the last 30 days? If "yes", please enter the date you were notified that you were no longer contagious with COVID-19. lick to customize text box label *

4. Have you been tested for COVID-19? If yes, when was the test and what were the results? *

5. Have you been tested for COVID-19 antibodies? If yes, what were the results? *
Have you had a COVID-19 Vaccine? Which type?*
No
Yes
J&J
Moderna
Pfizer BioNtech
Have you been boosted? What type?*
No
Yes
J&J
Moderna
Pfizer BioNtech
If a guest answers "yes" to questions 1-3, they will not be allowed on the trip. The decision to allow a formerly sick guest may be based on: At least 5 days (120 hrs) since fever has gone (without the use of fever-reducing medications) AND improvement in respiratory symptoms AND at least 10 days have passed since symptoms appeared.

Upon Arrival Guests will be asked about having any CV19 symptoms or if anything has changed since filling out the questionnaire and have their temperature taken. If they have a temperature of 100.4°F/38°C or higher, they and their immediate traveling party should not be allowed on the tour. TODAYS DATE *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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