COVID-19 Contact Tracing

Please take a few moments to complete this form.

Date*

Name*

Email*

Phone*

Are you feeling sick?*

(Examples include a new cough, headache, weakness, fever, difficulty breathing etc...)

Yes
No

In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?*

Yes
No

Have you travelled outside Canada in the past 14 days?*

Yes
No

Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill and you did not have appropriate PPE?*

Yes
No

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*

Yes
No

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?*

Yes
No

Please take a few moments to complete this form.

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