COVID-19 Exposure Form – Falls Church Soccer Association

This form is intended for coaches, staff, parents & volunteers to report any COVID-19 exposure or risk of exposure to prevent spread of the virus during Falls Church Soccer Association (FCSA) hosted activities.

Step 1: If a staff member, coach, volunteer, or player has answered "yes" to any of the below screening questions, then they should stay home for a minimum of ten days. After the ten day period, they should confirm a "yes" response no longer applies to the below questions before phasing back into FCSA hosted activities.

Step 2: Reporting COVID-19 exposure in this form. IF a staff member or coach becomes aware of any staff member, coach, volunteer, or player that has answered "yes", they should collaborate with that person/family to complete this COVID-19 Exposure Response Form to ensure proper steps have been taken to eliminate risk for future spread.

Step 3: FCSA staff will follow up with a reporting individual, staff member, or coach to confirm details and align on next steps.

Step 4: Reporting individual, FCSA staff member or coach (with guidance) will communicate with the participant and/or participant's family on appropriate next steps.

Any staff member, coach, volunteer, or player that has tested positive for COVID, we recommend he or she provide a doctor's note with a medical clearance in writing OR a negative COVID-19 test to return to FCSA activities.

Any staff member, coach, volunteer, or player that has been in a high risk scenario but has not been tested or tested positive must undergo a 10 day symptom-free quarantine.

If you have any questions about COVID-19, FCSA protocols or this COVID-19 Exposure Form, please reach out to the closest staff member for guidance. Thank you for your attention to this to support the safety of our Alexandria community.

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APPENDIX

Screening Questions

(If answer "yes" to any of the below questions, please have staff member, coach, volunteer, or player stay home)

(1) Have you received a positive test result for COVID-19?

(2) Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing, loss of taste/smell)?

(3) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

(4) Have you had close contact with or cared for someone who has experienced symptoms of COVID-19 within the last 14 days but has not been tested?

(5) Have you returned from international travel within the last 14 days?

(6) Have you been in close contact with anyone who has traveled internationally within the last 14 days?

* Required

Name of COVID-19 Exposed Staff, Coach, Volunteer or Player

Name of Reporting Staff Member, Coach or Parent

Name of Program or Team Participating In

Please select which Screening Questions that apply to exposed staff member, coach or player.

(1) Have you received a positive test result for COVID-19?

(2) Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing, loss of taste/smell)?

(3) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?

(4) Have you had close contact with or cared for someone who has experienced symptoms of COVID-19 within the last 14 days but has not been tested?

(5) Have you returned from international travel within the last 14 days?

(6) Have you been in close contact with anyone who has traveled internationally within the last 14 days?

COVID-19 EXPOSURE RESPONSE BACKGROUND DETAILS

Projected date of COVID-19 exposure:

Projected date became aware of the potential COVID-19 exposure:

Have you (the exposed individual) been fully vaccinated and the estimated exposure date is 14+ days after final vaccination dose?

Yes

Type of COVID test taken (if applicable):

Date of COVID test taken (if applicable):

Date COVID test results were received (if applicable):

COVID test result (if applicable):

Additional COVID Precautions during exposure scenario. Please check all that apply.

Participated in an outdoor FCSA activity

Mask worn when entering/exiting the facility

Mask worn when on sidelines, as substitute and when not actively playing

Mask worn while actively participating (not required)

Social distancing maintained when not actively playing

Player primarily played the goalkeeper position

No equipment shared beyond the ball

Any additional details of the potential COVID-19 exposure worth noting? Please include any initial communications, precautions or related notes to support next steps.

Have you notified an FCSA coach or staff member initially about the exposure scenario to help us reach out directly to support gather information and next steps. If so, please list name(s) below,

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