MASS YOUTH SOCCER MEMBER COVID EXPOSURE REPORTING FORM

Organization Name *

Name of Person Submitting Report *

Role with Soccer Organization *

Phone Number *

Email *

DATE OF EXPOSURE * +

DATE OF NOTIFICATION BY AFFECTED PERSON/PARENT/GUARDIAN * +

Date COVID-19 Notification Form was sent by your organization to those who would have been considered close contacts: +

DATE ORGANIZATION WAS NOTIFIED BY OR CONTACTED THE LOCAL DEPARTMENT OF PUBLIC HEALTH +

Please check here if organization has not been contacted by or reached out to DPH

No contact with DPH

Please provide any additional information: *