COVID-19 Exposure Response Form

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This form is intended for coaches, staff, parents & volunteers to report any COVID-19 exposure or risk of exposure to prevent spread of the virus during Alexandria Soccer Association (ASA) hosted activities.

STEP 1 — Report possible COVID-19 exposures in this form. IF a staff member or coach becomes aware of any staff member, coach or participant that falls under any of the screening questions, they should collaborate with that person/family to complete this COVID-19 Exposure Response Form to ensure proper steps have been taken to eliminate risk for future spread.

STEP 2 — ASA staff will follow up with the reporting person, staff member or coach to confirm details, assess the exposure scenario, and align on next steps.

STEP 3 -- Reporting person, ASA staff member or coach (with guidance) will communicate with the participant and/or participant's family on appropriate next steps.

If you have any questions about COVID-19, ASA protocols or this COVID-19 Exposure Response Form, please reach out to the closest ASA front-office staff member for guidance. Thank you for your attention to this and for supporting the safety of our Alexandria community.

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APPENDIX
Screening Questions
(If answer “yes” to any of the below questions, please have staff member, coach or participant stay home)

(1) Have you received a positive test result for COVID-19?

(2) Have you experienced any cold or flu-like symptoms in the last 10 days (to include fever, cough, sore throat, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste/smell, sore throat, congestion or runny nose, diarrhea, nausea or vomiting)?

(3) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 10 days?

(4) Have you had close contact with or cared for someone who has experienced symptoms of COVID-19 within the last 10 days but has not been tested?

Email *

Name of COVID-19 Exposed Staff, Coach or Participant *

Name of Reporting Staff Member, Coach or Parent *

Name of Program or Team Participating In *

Please select which Screening Questions that apply to exposed staff member, coach or participant. *

(1) Have you received a positive test result for COVID-19?

(2) Have you experienced any cold or flu-like symptoms in the last 10 days (to include fever, cough, sore throat, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste/smell, sore throat, congestion or runny nose, diarrhea, nausea or vomiting)?

(3) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 10 days?

(4) Have you had close contact with or cared for someone who has experienced symptoms of COVID-19 within the last 10 days but has not been tested?

Required

COVID-19 EXPOSURE RESPONSE BACKGROUND DETAILS

Projected date of COVID-19 exposure: *

Date became aware of the potential COVID-19 exposure: *

YYYY

Date symptoms (if any) first appeared:

YYYY

Have you (the exposed individual) been fully vaccinated and the estimated exposure date is 14+ days after final vaccination dose? *

Yes

Type of COVID test taken (if applicable): *

Date & time of COVID test taken (if applicable): *

Date & time that COVID test results were received (if applicable): *

COVID test result (if applicable): *

Additional COVID Precautions during exposure scenario. Please check all that apply. *

Participated in an outdoor ASA activity

Mask worn when entering/exiting the facility

Mask worn when on sidelines, as substitute and when not actively playing

Mask worn while actively participating (not required)

Social distancing maintained when not actively playing

Participant primarily played the goalkeeper position

No equipment shared beyond the ball

Required

Any additional details of the potential COVID-19 exposure worth noting? Please include any initial communications, dates of recent ASA activities, precautions or related notes to support next steps. *

Have you notified an ASA coach or staff member initially about the exposure scenario to help us reach out directly to support gather information and next steps. If so, please list name(s) below, *

Send me a copy of my responses.

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