COVID-19 Positive Test Report Form
AYSO Region 88 Glendale / La Crescenta / Montrose
Submission form for any player or volunteer who has tested positive for COVID-19
Please start your isolation period right away as per L.A. County guidelines. Please also inform your school or other organizations where you spend time if you have not done so already.
This report is for a:
Player who tested positive
Player's Division (Age Group)
U4 / 5U
Volunteer who tested positive
Cell Phone Number
Please enter a valid phone number.
Date test performed
Date results received
Date of first symptoms
Type of Test
PCR or other NAAT test
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)
Please provide information regarding the exposed person's symptoms currently being experienced.
Does the person who tested positive have any of the symptoms listed below:
Please indicate the symptoms the affected person are currently having:
Shortness of breath
Loss of taste or smell
Muscle or body aches
Nausea or vomitting
Congestion or runny nose
No symptoms at this time
Please provide dates and descriptions of any attendance of the player/volunteer to AYSO games or practices, starting 3 days prior to the positive test or start 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 with 2-doses for Moderna or Pfizer or 1 shot for J&J
Partially vaccinated with 1 dose of Moderna or Pfizer
Has someone from the team been notified of this COVID-19 diagnosis or exposure (including if the affected person is the players' parent)?
Confirmed Test Results
Drag and drop files here
Choose a file
Required for Players/Volunteers who have tested positive more than 10 days ago, and less than 90 days ago (COVID immunity)
Any additional information or comments:
Should be Empty: