Name of Person Submitting Report *

First Name

Last Name

Infected Individual *

First Name

Last Name

Coach's Name *

First Name

Last Name

Parent's Name *

First Name

Last Name

Parent's Phone Number

(###)

###

####

Date of Covid-19 Diagnosis *

MM

DD

YYYY

When did signs or symptoms begin? *

MM

DD

YYYY

Where did symptoms begin? *

During Force Training or Game

Outside of Force

What were the signs & symptoms? *

Please check all of the symptoms that apply.

Fever > 100.4º F

Cough

Shortness of Breath

Headache

Nausea or Vomiting

Diarrhea

Muscle or Joint Pain

Sore Throat

Chills

Loss of Taste or Smell

Unusual Rash

Other