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.

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?


Have you received a notification from the COVID Alert app that you may have been exposed to COVID-19?


Were you outside of Newfoundland & Labrador in the last 14 days? (This excludes the communities along the Labrador-Quebec border including Labrador City, Wabush, Fermont, the Labrador straits area and Blanc Sablon)


In the last 14 days, did you have close contact with an ill person who travelled outside of Newfoundland & Labrador?


Are you a:


In the last 14 days, did you work at or visit a place with a COVID-19 outbreak? (e.g., work camp, bar, wedding, funeral, etc.)


Do you work in the following within Newfoundland and Labrador?

  • Healthcare
  • Coast guard
  • RNC
  • RCMP
  • Fire Services
  • Correctional Facilities
  • Transportation of essential goods
  • Grocery Store
  • Daycare Centre
  • Shelter
  • Transition House
  • Other housing programs servicing vulnerable populations


Do you attend any of the following within Newfoundland and Labrador?

  • Daycare
  • Shelter
  • Transition House


Do you require a COVID-19 test as a result of an advisory from Public Health? (e.g., a flight or a public place connected to a COVID-19 case)


Date of Birth