This form should be filled out if an MBA player or coach, or a member of the player or coach's household, has COVID-19 positive test result.

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* 1. Name of the Participant (the MBA player or MBA coach) about whom this form is being completed; subsequent questions refer to that Participant

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* 2. Name of the person completing this form on behalf of the Participant (e.g. the MBA player's parent/guardian completing the form about their child or the MBA coach completing the form about themselves)

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* 3. email address for the person completing the form

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* 4. Cell phone number for the person completing the form

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* 5. Grade level of the Participant

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* 6. Program the Participant is a part of

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* 7. Type in the name of head coach for the Participant's team

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* 8. What COVID-19 symptoms is the Participant experiencing? (if no symptoms for the MBA participant, leave blank)

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* 9. Are you reporting a COVID-19 positive case for an MBA particpant (player or coach) OR for a household member of an MBA participant?

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* 10. What date did the MBA Participant's symptoms begin? (if no symptoms type leave blank)

Date

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* 11. What date was the Participant's COVID-19 (positive result) test taken (MM/DD/YYYY)?  (Leave blank if test not taken)

Date

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* 12. What date was the Participant's COVID-19 test result received (MM/DD/YYYY)?  (Leave blank if no test result)

Date

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* 13. What is the last date that the MBA Participant was Close Contact Exposed to a household Positive Case of COVID-19 (MM/DD/YYYY)?   (What date did the positive household member begin to self-isolate in the home?)   (If not reporting household close contact for the Participant, then leave blank.)

Date

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* 14. What is the last date that the Participant had contact with their MBA team (MM/DD/YYYY)?

Date

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* 15. In the event of multiple exposures (e.g multiple family members test positive) please describe last date of exposure (last point of contact) with each positive case.

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