Pre Quarantine (self isolation) questionnaire

Name

First NameLast Name

Email

example@example.com

Date of birth

Date

Phone Number

Area CodePhone Number

Name of Project/Production

Arrival Date in Canada

Date

Address of Quarantine ( if known )

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Describe situation most compatible for your planned quarantine ?

Family unitSingle individualSmall groupOther

How many people will be with you in the quarantine ?

Where do you live ?

Street Address

Street Address Line 2

CityState / Province

Country

How many people live in your household ?

Do you have any kids ? if yes indicate number of kids who live in your household and ages

WORK OGANISATION Choose answer that apply to you situation

Social interactions in the last 2 weeks

Minimal , mostly at homeOccasional activities with friends and familyno restrictions on social activitiesOther

DID you travel recently ? ( If yes describe )

Describe situation that apply best to your situation

I always wear a mask in public spacesI never wear a mask in public spacesI occasionally wear a mask in public spacesI maintain a 2 m distance all the time ?I maintain a 2 m distance sometimes ?Other

Any high risk situation of exposure to COVID-19 by a member of your family/Unit in the last 10-14 days ?

YESNO

IF YES Please describe

Do you have a medical condition such as High blood pressure, diabetes, respiratory disease or do you take any medication that can affect you immunity ?

YESNO

If YES, please Specify

Have you been tested for COVID in the past, been diagnosed with COVID-19 or think that you have had it ( undiagnosed )

YESNO

If YES, please Specify ( Diagnostic , test or sick, When, Where, How )

Do you have any specific questions on the quarantine ? ( A detailed quarantine plan will be sent to you shortly after completing this form)

Pre Quarantine (self isolation) questionnaire

Quarantine Details

Family & Work

Use of Protective equipment

A short phone interview may be needed to complete the risk assessment