NVSC COVID 19 Notification Form
Please complete the following form so NVSC can submit the information to the PWC Department of Health and to ensure sufficient information for contact tracing if necessary.  Please submit a separate form for each player in your household affected.  All information will be kept confidential and will only be shared with appropriate staff to ensure sufficient tracking.
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Email *
Name of person submitting form *
Player FIRST Name (submit a separate form for each NVSC player in your home) *
Player LAST Name *
Affected person is: *
Required
Players Team & Coach *
My Player .... *
Required
Date of diagnosis / exposure date range (please indicate if the date is the date of diagnosis or exposure)  If there has been a test - please indicate test date as well. (For example:  12/28/21 Exposed / 1/04 Tested / 1/04 diagnosed) If returning from international travel, indicate date you returned to the US *
Date symptoms first appeared (if applicable)
MM
/
DD
/
YYYY
What symptoms is your player currently experiencing? *
If your player was exposed but not diagnosed, what were the circumstances of that exposure? *
If you chose "other" to the question above, please explain the circumstances"
When was the last date you attended an NVSC training or event? *
MM
/
DD
/
YYYY
Please list the names of any NVSC players with whom your player carpools or otherwise has interacted with in person in your home, in their home, or in the community.    If NONE indicate NONE *
Please list the names of any siblings in the home who are also NVSC players along with the names of any players who those siblings may have had contact with.  If NONE indicate NONE *
Has the person in question been vaccinated? *
Please provide any additional information you think relevant.
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