JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Reporting Confirmed COVID-19 Infection
If your player has tested positive for COVID-19, we ask that you please complete this form. We assure you that your privacy will be protected and your medical information will remain confidential.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
PTFC Team Name (ex. PTFC 09 Black or PTFC 09 Lady Black)
*
Your answer
When did you begin exhibiting symptoms?
*
MM
/
DD
/
YYYY
When were you diagnosed?
*
MM
/
DD
/
YYYY
Where do you suspect you became infected?
*
Your answer
Were you provided a treatment plan?
*
Yes
No
Unsure
If so, please describe the plan. (ex. quarantine, hospital stay, home care, etc.)
Your answer
Have you completed the plan?
*
Yes
No
Have you been released by a health care provider?
*
Yes
No
When was the last time you participated in a PTFC activity?
*
MM
/
DD
/
YYYY
Have you interacted with any PTFC members OUTSIDE of PTFC training/games?
*
Yes
No
If So, please list all names of PTFC members that you have interacted with.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
