COVID-19 Exposure Status for AYSO Region 13
This form is to alert us that you have been exposed to a COVID-19 Case
If you as a Volunteer for Region 13, or your child as a player or volunteer for Region 13, have been exposed to a person who tested positive for COVID-19, please fill out this form and self-isolate as per guidelines.
For example, if a player has been notified by the school that there was a close contact or an exposure to a COVID case and that the player must self-isolate (quarantine), then please complete this form and honor the self-isolation as per LA County guidelines. The form will help us keep track of players and volunteers who are not available to participate due to self-isolation. Thank you.
Full Name of person who had the exposure
*
First Name
Last Name
Where did the exposure(s) happen?
*
AYSO Practice
AYSO Game
School
University
Job location
Home (e.g. a family member)
Other
Name of School
*
Has the exposed person received quarantine instructions from organization where exposure occurred or from a Public Health Department?
*
Yes
No
The person who was exposed is a
*
Child
Adult volunteer
Full name of Child's parent
*
First Name
Last 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 exposed person plays or volunteers
*
4U/5U
VIP
B6U
G6U
B7U
G7U
B8U
G8U
B10U
G10U
B12U
G12U
B14U
G14U
B16U
G16U
B19U
G19U
EXTRA
Other
Name of coach of the team
*
indicate if you don't know
Date of exposure
*
-
Month
-
Day
Year
Date
Symptoms
Please provide information regarding the exposed person's symptoms currently being experienced.
Does the exposed person have any of the symptoms listed further below?
*
Yes
No
When did symptoms start?
*
-
Month
-
Day
Year
Date
Please indicate the symptoms the exposed person is currently having:
Cough
Shortness of breath
Fever
Loss of taste or smell
Sore throat
Fatigue
Muscle or body aches
Nausea or vomiting
Diarrhoea
Congestion or runny nose
No symptoms at this time
Other
Has the exposed person been fully or partially vaccinated against COVID-19?
Fully vaccinated AND booster dose
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
Have the player's/volunteer's coach and team manager been notified of this COVID-19 exposure?
Coach
Manager
Coach and Manager
Not notified
Any explanatory remarks:
Submit
Should be Empty: