If you are completing this form on behalf of someone else, (i.e. your child, a family member or patient), please answer the following questions from their perspective rather than your own.

Were you infected with COVID-19 in the last 3 months?


Please select the symptoms that you are currently experiencing











OR


In the last 14 days, have you been in close contact with a known case of COVID-19?


Do you have any rapid self-tests available to you at home (at least two)?


Did you receive a positive result on a COVID-19 rapid self-test (i.e. self-administered test)?


Are you a frontline health care worker with direct patient care?


Are you in one of the following groups?

  • You work in a long-term care home, personal care home, community care home, assisted living facility.
  • You work in a correctional facility.
  • You live in or work in a shelter, transition house, or temporary foreign worker setting.

  • Are you pregnant?


    Are you First Nations, Inuit or Métis?


    Do you participate in an asymptomatic workplace screening program through Public Health (i.e., staff in long-term care, personal care homes, assisted living facilities, community care homes, co-ops, correctional facilities, emergency shelters, treatment centres, or residential care homes for children and youth)?


    Are you being admitted to, a long-term care facility, personal care home, community care home, or assisted living facility?


    Are you in one of the following immunocompromised groups?

  • You are undergoing cancer treatment
  • You had a solid organ transplant and you are taking immunosuppressive therapy
  • You had a stem cell transplant in the last 2 years
  • You had CAR-T cell treatment in the last 2 years
  • You have a moderate or severe primary immunodeficiency (diagnosis of DiGeorge syndrome, Wiskott-Aldrich syndrome, common variable immunodeficiency, Good’s syndrome or hyper IgE syndrome).
  • You have advanced or untreated HIV (does not apply if you have an undetectable viral load)
  • You are taking high dose corticosteroids (e.g., 20 mg or greater of prednisone daily for over 2 weeks)
  • You are taking a highly immunosuppressive drug (biologic medication, transplant or chemotherapy related immunosuppressant)

  • Please enter date of birth for yourself or whoever requires the COVID-19 test.