COVID-19 Positive Test Report for AYSO Region 13

AYSO Region 13 Positive COVID Test Report
If your child tests positive for COVID, or you are a Volunteer and test positive for COVID, please fill out this form. Thank you.

Your information will be kept private, shared only with the Region 13 Covid Team, your Coach, and, if required by Health Orders, the Pasadena or LA County Public Health Authorities.
If you haven't already done so, please inform your AYSO coach right away and follow isolation instructions from your school or Health Department.
Full Name of person who tested positive*

First NameLast Name
Was the test done at a school or for a school?*

YesNo
Name of School*
The person who tested positive is a*

ChildAdult volunteer
Full name of Child's parent*

First NameLast Name
Email Address for Parent or Adult Volunteer*
example@example.com
Best phone number for Parent or Adult Volunteer (cell preferred)*
Please enter a valid phone number.
Division(s) where the person who tested positive plays or volunteers*

4U/5UVIPB6UG6UB7UG7UB8UG8UB10UG10UB12UG12UB14UG14UB16UG16UB19UG19UEXTRAOther
Name of Coach of the team*
Indicate if you don't know
Email address of the Head Coach of the team
Please fill this in if you have the email address for your Coach. The email address provided here will be sent a copy of your report.
Date test was performed*

MonthDayYear
Date
Date results were received*

MonthDayYear
Date
PCR or other NAAT testAntigenHome TestOther
Any other details on the test?
e.g. specific type of test, brand of test, where was the test administered (e.g. pharmacy, lab, or testing site name)
Symptoms

Please provide information regarding the player's or volunteer's symptoms currently being experienced.
Does the person who tested positive currently have any symptoms?*

YesNo
When did symptoms start?

MonthDayYear
Date
When did the person who tested positive last have contact with the team?

MonthDayYear
Date
Please indicate the symptoms the affected person is currently having:

CoughShortness of breathFeverLoss of taste or smellSore throatFatigueMuscle or body achesNausea or vomitingDiarrheaCongestion or runny noseNo symptoms at this timeOther
Please provide dates and descriptions of any attendance of the player/volunteer to AYSO games or practices, starting 3 days prior to the COVID-19 positive test or to the onset of any symptoms:*
Even if you only vaguely recall these things, putting down what you can will help with contact tracing. Note that your identity will not be divulged to your team or to any opponents your team played.
Has the affected person been fully or partially vaccinated against COVID-19?

Fully vaccinated AND booster dose (or two booster doses if age 50 or over)Fully vaccinated with 2-doses for Moderna or Pfizer or 1 shot for J&J.Partially vaccinated with 1 dose of Moderna or Pfizer.NoOther
Have the player's/volunteer's coach and team manager been notified of this COVID-19 diagnosis?

CoachManagerCoach and ManagerNot notified
Any explanatory remarks:
Should be Empty:

AYSO Region 13 Positive COVID Test Report

If your child tests positive for COVID, or you are a Volunteer and test positive for COVID, please fill out this form. Thank you.

If you haven't already done so, please inform your AYSO coach right away and follow isolation instructions from your school or Health Department.

Symptoms