Phoenixville Area Soccer Club COVID Health Report

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All members (players, coaches, staff) are required to complete the PASC Health Report / Tracking form if they or a household member:

1. are experiencing symptoms of COVID-19, are awaiting test results, or have tested positive for SARS-CoV2
2. have been in contact with someone who has confirmed or suspected COVID-19 infection, or
3. are under quarantine

Once a submission is made, all household members should refrain from attending PASC activities until cleared by a member of PASC's COVID committee.

The information transmitted by this form will be used by PASC administration to determine appropriate follow-up and club mitigations actions. We will make every attempt to anonymize any necessary communication to the team.

By completing this form, you are assisting the club to maintain a safe environment for our members. Be honest in your evaluation and be responsible to yourself, your family, and your community.

Email *

FIRST Name of ill/potentially ill individual *

LAST Name of ill/potentially ill individual *

Primary Phone *

Gender *

Male

Female

Birth Year *

Team Name *

Reason for this report *

Confirmed COVID-19 case

Possible COVID-19 case

Notification of Self/Medical Quarantine

Notification that Family/Household member is under quarantine

Updating Information/Closing of Active Health Report

Other:

If you responded "Other" to the previous question or wish to provide additional information/details, please describe:

Is individual fully vaccinated? *

Yes

Prefer not to say

If you are in self- or medical quarantine, list date of the start of quarantine.

YYYY

Date you were last at a PASC event *

YYYY

A copy of your responses will be emailed to the address you provided.

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