COVID-19 Incident Report Form
Waxhaw Soccer is committed to protecting the privacy of the health information of its members, to maintaining the security of its paper, oral and electronic submissions of health information, and to complying with the standard electronic transactions provisions, as required by the Health Insurance Portability and Accountability Act of 1996, the regulations promulgated thereunder, and the changes mandated by the HITECH Act.

We are confident that our focus and commitment will ensure the greatest level of privacy and security of all member protected health information, while minimizing any impact on our high standards for customer service.

This form has been created in compliance with HIPAA.
Email *
First Name and Last Name of Person Completing This Form *
Name of Player who has been exposed/symptomatic/tested *
Team Name, Age Group, Coach *
Has the Individual Been Completely Vaccinated? *
Symptoms: COVID-19 Symptoms Include: Fever, Chills, Shortness of breath or difficulty breathing, New cough, New loss of taste or smell, Congestion or Runny Nose, Headache, Muscle Pain, Sore Throat, Fatigue, Nausea or Vomiting, Diarrhea. If an individual has any of these symptoms, they should go home, stay away from other people, and call or have a guardian call their health care provider. Is the player experiencing any of these symptoms? *
Has the Player/Coach had Direct Exposure with someone who tested positive for COVID-19? *
Has the Player/Coach had Direct Exposure with someone with symptoms? *
Please explain how the contact happened. If available, please provide the explanation the school/establishment has explained the exposure. *
Please provide the exact date of exposure, if possible, to assist in determining return-to-play potential dates. If you cannot provide an exact date, please give us an estimate or give us the date of the first symptoms. *
Has the player been tested for COVID-19? *
Please include any additional information you would like to share. *
You must immediately contact our Waxhaw Soccer COVID case manager to confirm that you have completed this form and are ready for a verification of return-to-play date. Check both boxes and then submit. *
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