BRHA National: NHS Test & Trace (v2)
.
Please note contact information has been hidden for privacy reasons. Contact the BRHA National Executive Committee (
nationalexec@brha.co.uk
) or your regional head if you require this information.
To download a copy of our latest RTP guidance, head over to
https://brha.co.uk/documents
Our Test & Trace form has changed:
Following revised Government and DCMS guidance, key changes have been made to this form requiring the addition of contact details for all individuals aged 16 and over. This is to ensure everyone receives the necessary public health advice in a timely manner. You can now also note the result of a lateral flow test if you so wish. Unfortunately, we have had to remove the automated copy for future submissions meaning data needs to be entered manually each time you submit a Test & Trace form.
To download a copy of our latest RTP guidance, head over to
https://brha.co.uk/documents
I am a...
I am a...
League Official
Manager / Coach
Player
Parent / Guardian
Please select the BRHA region or enter the venue name:
Please select the BRHA region or enter the venue name:
Please select one ...
3on3 Iron Hockey (Bordon)
BRHA North Wales (Market Drayton)
BRHA North West (Atherton)
BRHA South (Bordon)
BRHA South West (Plymouth)
BRHA West (Market Drayton)
BRHA Yorkshire (Sheffield)
Other / Training Venue
Please enter the venue name and location:
Please enter the venue name and location:
Which club are you registered/associated with?
Which club are you registered/associated with?
Club/Team:
Team not listed? Add it here...
Team not listed? Add it here...
In which age group?
In which age group?
Please select one ...
Seniors
Under 16
Under 14
Under 12
Under 10
Please enter your details:
Please enter your details:
Lead Name
Phone Number
Email Address
Team Name
Please list other people in your party:
Please list other people in your party:
Full Name
Phone Number
Email Address
Other 1)
Other 1) Full Name
Other 1) Phone Number
Other 1) Email Address
Other 2)
Other 2) Full Name
Other 2) Phone Number
Other 2) Email Address
Other 3)
Other 3) Full Name
Other 3) Phone Number
Other 3) Email Address
Other 4)
Other 4) Full Name
Other 4) Phone Number
Other 4) Email Address
Other 5)
Other 5) Full Name
Other 5) Phone Number
Other 5) Email Address
Other 6)
Other 6) Full Name
Other 6) Phone Number
Other 6) Email Address
Other 7)
Other 7) Full Name
Other 7) Phone Number
Other 7) Email Address
Other 8)
Other 8) Full Name
Other 8) Phone Number
Other 8) Email Address
Other 9)
Other 9) Full Name
Other 9) Phone Number
Other 9) Email Address
Other 10)
Other 10) Full Name
Other 10) Phone Number
Other 10) Email Address
Other 11)
Other 11) Full Name
Other 11) Phone Number
Other 11) Email Address
Other 12)
Other 12) Full Name
Other 12) Phone Number
Other 12) Email Address
Other 13)
Other 13) Full Name
Other 13) Phone Number
Other 13) Email Address
Other 14)
Other 14) Full Name
Other 14) Phone Number
Other 14) Email Address
Other 15)
Other 15) Full Name
Other 15) Phone Number
Other 15) Email Address
Other 16)
Other 16) Full Name
Other 16) Phone Number
Other 16) Email Address
Other 17)
Other 17) Full Name
Other 17) Phone Number
Other 17) Email Address
Other 18)
Other 18) Full Name
Other 18) Phone Number
Other 18) Email Address
Other 19)
Other 19) Full Name
Other 19) Phone Number
Other 19) Email Address
Other 20)
Other 20) Full Name
Other 20) Phone Number
Other 20) Email Address
Other 21)
Other 21) Full Name
Other 21) Phone Number
Other 21) Email Address
Other 22)
Other 22) Full Name
Other 22) Phone Number
Other 22) Email Address
Other 23)
Other 23) Full Name
Other 23) Phone Number
Other 23) Email Address
Other 24)
Other 24) Full Name
Other 24) Phone Number
Other 24) Email Address
Other 25)
Other 25) Full Name
Other 25) Phone Number
Other 25) Email Address
Date & time of arrival and expected departure:
Date & time of arrival and expected departure:
Date of Visit:
Expected Arrival Time:
Estimated Departure Time:
Date & time of arrival and expected departure:
Date & time of arrival and expected departure:
Date of Visit
Arrival Time (24hr)
Departure Time (24hr)
Date of Visit
Arrival Time (24hr)
Departure Time (24hr)
Attendee Count
Attendee Count
Lead Person
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10
Person 11
Person 12
Person 13
Person 14
Person 15
Person 16
Person 17
Person 18
Person 19
Person 20
Person 21
Person 22
Person 23
Person 24
Person 25
Add results of Lateral Flow Test
Results of most recent Lateral Flow Test
Results of most recent Lateral Flow Test
Test Date
Result
Comment (if applicable)
{Q9.A1} Test Date
Negative
Positive
{Q9.A1} Result
{Q9.A1} Comment (if applicable)
{Q10.A1.C1} Test Date
Negative
Positive
{Q10.A1.C1} Result
{Q10.A1.C1} Comment (if applicable)
{Q10.A2.C1} Test Date
Negative
Positive
{Q10.A2.C1} Result
{Q10.A2.C1} Comment (if applicable)
{Q10.A3.C1} Test Date
Negative
Positive
{Q10.A3.C1} Result
{Q10.A3.C1} Comment (if applicable)
{Q10.A4.C1} Test Date
Negative
Positive
{Q10.A4.C1} Result
{Q10.A4.C1} Comment (if applicable)
{Q10.A5.C1} Test Date
Negative
Positive
{Q10.A5.C1} Result
{Q10.A5.C1} Comment (if applicable)
{Q10.A6.C1} Test Date
Negative
Positive
{Q10.A6.C1} Result
{Q10.A6.C1} Comment (if applicable)
{Q10.A7.C1} Test Date
Negative
Positive
{Q10.A7.C1} Result
{Q10.A7.C1} Comment (if applicable)
{Q10.A8.C1} Test Date
Negative
Positive
{Q10.A8.C1} Result
{Q10.A8.C1} Comment (if applicable)
{Q10.A9.C1} Test Date
Negative
Positive
{Q10.A9.C1} Result
{Q10.A9.C1} Comment (if applicable)
{Q10.A10.C1} Test Date
Negative
Positive
{Q10.A10.C1} Result
{Q10.A10.C1} Comment (if applicable)
{Q10.A11.C1} Test Date
Negative
Positive
{Q10.A11.C1} Result
{Q10.A11.C1} Comment (if applicable)
{Q10.A12.C1} Test Date
Negative
Positive
{Q10.A12.C1} Result
{Q10.A12.C1} Comment (if applicable)
{Q10.A13.C1} Test Date
Negative
Positive
{Q10.A13.C1} Result
{Q10.A13.C1} Comment (if applicable)
{Q10.A14.C1} Test Date
Negative
Positive
{Q10.A14.C1} Result
{Q10.A14.C1} Comment (if applicable)
{Q10.A15.C1} Test Date
Negative
Positive
{Q10.A15.C1} Result
{Q10.A15.C1} Comment (if applicable)
{Q10.A16.C1} Test Date
Negative
Positive
{Q10.A16.C1} Result
{Q10.A16.C1} Comment (if applicable)
{Q10.A17.C1} Test Date
Negative
Positive
{Q10.A17.C1} Result
{Q10.A17.C1} Comment (if applicable)
{Q10.A18.C1} Test Date
Negative
Positive
{Q10.A18.C1} Result
{Q10.A18.C1} Comment (if applicable)
{Q10.A19.C1} Test Date
Negative
Positive
{Q10.A19.C1} Result
{Q10.A19.C1} Comment (if applicable)
{Q10.A20.C1} Test Date
Negative
Positive
{Q10.A20.C1} Result
{Q10.A20.C1} Comment (if applicable)
{Q10.A21.C1} Test Date
Negative
Positive
{Q10.A21.C1} Result
{Q10.A21.C1} Comment (if applicable)
{Q10.A22.C1} Test Date
Negative
Positive
{Q10.A22.C1} Result
{Q10.A22.C1} Comment (if applicable)
{Q10.A23.C1} Test Date
Negative
Positive
{Q10.A23.C1} Result
{Q10.A23.C1} Comment (if applicable)
{Q10.A24.C1} Test Date
Negative
Positive
{Q10.A24.C1} Result
{Q10.A24.C1} Comment (if applicable)
{Q10.A25.C1} Test Date
Negative
Positive
{Q10.A25.C1} Result
{Q10.A25.C1} Comment (if applicable)
COVID-19 Symptom Disclaimer
I confirm that the individuals listed in this NHS Test & Trace form have not displayed symptoms or had a confirmed diagnosis of COVID-19 within the last 14 days, nor are awaiting a test or test results. The recognised symptoms can be found on the NHS UK website:
https://www.nhs.uk/conditions/coronavirus-covid-19/symptoms/
. We ask that if you are feeling generally unwell that you also not attend the rink to help us mitigate risk.
I confirm the above COVID-19 statement
Assumption of the Risk & Waiver of COVID-19 Liability
The BRHA has put in place preventative measures to help prevent the spread of COVID-19 but, however, cannot guarantee that you or anybody listed on this NHS Test & Trace form will not become infected. I, as the lead contact, accept full responsibility and acknowledge the steps the BRHA and the respective facility have taking to help mitigate risk amidst the Coronavirus global pandemic.
I agree to the above risk assumption and waiver of liability statement
Sum of Attendee Count
Sum of Attendee Count
SetValue
SetValue
Atherton
Bordon
Market Drayton
Other
Plymouth
Yorkshire
Venue_Dashboard_GroupFilter
Venue_Dashboard_GroupFilter
FORM
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