PLSHA COVID-19 Reporting Form
PLSHA has created this form in response to Minnesota Hockey Return to Play Guidelines. Minnesota Hockey states families must “inform your team and/or association COVID-19 contact of a player testing positive, someone in their household testing positive or have been exposed to someone confirmed to have COVID-19.”

DIRECTIONS:
1. Complete this form in its entirety.
2. You will complete one form form for each association member (i.e., if you have a player and a coach who have been exposed by another family member you will complete for both; if you have a player who tested positive, then you complete for the parent/coach who was exposed). To be compliant with MDH and Minnesota Hockey, PLSHA must have name and date of birth recorded along with the requested information, by person.
3. Submit form.
4. No participation in association activities until you have heard from PLSHA COVID-19 Managers.
5. Review the Minnesota Department of Health Decision Tree and MDH guidance for youth sports. You can find resources at the end of this form, on emails from PLSHA COVID-19 Managers, and on plsha.com/covid-19.

AFTER YOUR FORM IS SUBMITTED:
1. PLSHA COVID-19 Managers will review information, typically within a few hours.
2. When required by MDH & Minnesota Hockey, PLSHA COVID-19 Managers will provide required information to MDH and await MDH guidance. It can take until the next business day to receive the necessary reply and guidance from MDH. Please note: We invite you to be responsive to follow up emails/calls from PLSHA COVID-19 Managers; if you don’t reply to PLSHA COVID-19 Managers emails/calls for required information you may delay this process.
3. PLSHA COVID-19 Managers will email you (possibly phone) information, such as outcome to MDH consultation, return to association activities date, link to the MDH guidelines to follow, etc.
4. When necessary, PLSHA COVID-19 Managers will notify coaches via email of the unnamed player/coach status and resulting MDH guidance.
Note: If you opt not to provide identifying information such as player name, it may impact contact tracing; yet per Minnesota Hockey you are required to “inform your team and/or association COVID-19 contact of a player testing positive, someone in their household testing positive or have been exposed to someone confirmed to have COVID-19.”

By completing this form, I understand that PLSHA will comply with applicable state laws and the Minnesota Department of Health requirement to report the name and date of birth of a player or coach, with COVID-19 positive test results, as well as date of test, date of symptom onset, date of last association activity, and other required information to allow MDH to provided the required guidance for return to play.

Furthermore, the information in this document is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. The knowledge and circumstances around COVID-19 are changing constantly and, as such, Prior Lake Savage Hockey Association makes no representation and assumes no responsibility for the accuracy or completeness of this information.
Email address *
Name of Person Completing this Form *
Your Email for Follow Up Questions *
Your Phone Number for Follow Up Questions *
If you have multiple family members within the association, you will need to complete A SEPARATE form for EACH PERSON (i.e., mites player, squirts player, squirts coach). For whom/what are you reporting on this form? *
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