COVID-19 Exposure Status for AYSO Region 13

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:
Should be Empty:

COVID-19 Exposure Status for AYSO Region 13

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.

Symptoms