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2024 Infectious Disease Reporting Form
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* Indicates required question
Email
*
Your email
Your Name
*
Your answer
Your Contact Address:
*
Your answer
Your Cell Phone Number:
*
Your answer
Your Role:
*
Choose
Club President
Club VP
Club Secretary
Club Treasurer
Club Boys Rep
Club Girls Rep
Club Safety Manager
Coach
Club Administator
Parent
Player
Official
Assignor
Officials Orgainzation Board Member
NCJLA Board Member
Other
Report Information
Date of reported exposure, active infection or failed screening:
*
MM
/
DD
/
YYYY
Time of reported exposure, active infection or failed screening:
*
Time
:
AM
PM
Team affiliation of the person with reported exposure, active infection or failed screening:
*
Your answer
Venue Location of the reported exposure, active infection or failed screening:
*
Your answer
County in which the reported exposure, active infection or failed screening occured:
*
Your answer
Type of Report?
*
Reported Exposure
Active Infection
Failed Screening
Required
Event type in which the reported exposure, active infection or failed screening occured:
*
Game
Practice
NCJLA Event
Other
Required
List all of the other Clubs or Organizations that should be notified:
*
Please list the lacrosse clubs names, Officials organizations, etc...
Your answer
Boys or Girls Game?
*
Boys
Girls
Both
Required
If this happened at a game, what are the names of the clubs/teams involved?
Name of HOME team?
Your answer
Name of AWAY team?
Your answer
HOST Club name:
Your answer
Please briefly describe the details of the exposure, active infection or failed screening:
*
Your answer
I agree to inform any persons or organizations that could be impacted by this Covid-19 Infection case within the next 24 hours. I will report this cae to our county public health department for contract tracing.
*
I agree to the above.
Required
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