COVID-19 Positive Test Report Form
AYSO Region 88 Glendale
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
Volunteer
Other
Contact Information
Parent/Guardian Name
*
First Name
Last Name
Player who tested positive
*
First Name
Last Name
Player's Division (Age Group)
U4 / 5U
6U
7U
8U
10U
12U
14U
16U
19U
VIP
Volunteer who tested positive
*
First Name
Last Name
Primary Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Testing
Date test performed
*
-
Month
-
Day
Year
Date
Date results received
*
-
Month
-
Day
Year
Date
Date of first symptoms
-
Month
-
Day
Year
Date
Type of Test
*
PCR or other NAAT test
Antigen
Home Test
Other
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 exposed person's symptoms currently being experienced.
Does the person who tested positive have any of the symptoms listed below:
*
Yes
No
Please indicate the symptoms the affected person are currently having:
Cough
Shortness of breath
Fever
Loss of taste or smell
Sore throat
Fatigue
Muscle or body aches
Nausea or vomitting
Diarrhea
Congestion or runny nose
No symptoms at this time
Other
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
No
Other
Has someone from the team been notified of this COVID-19 diagnosis or exposure (including if the affected person is the players' parent)?
Head Coach
Assistant Coach
Team Parent
Not notified
Other
Confirmed Test Results
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Required for Players/Volunteers who have tested positive more than 10 days ago, and less than 90 days ago (COVID immunity)
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