COVID-19 Testing Assessment Form

Date of Travel

First Name

Last Name

Address

City & Postal Code

Phone

Birth Date

Health Card Number including the 2 letters (enter passport # if no Health Card available)

Gender

Female Male

In the last 14 days, did you return from travel outside of Canada?

Yes No

In the past 14 days, have been identified as close contact of someone who is confirmed as COVID 19. A close contact is defined as a person: 1) who provided care for the patient, including healthcare workers, family members or other caregivers. or 2) Who had other similar close physical contact or 3) Who lived with otherwise had close prolonged contact with a probable or confirmed case while the case was ill

Yes No

Have you been advised to get tested for COVID-19 by your local public Health unit due to exposure to a confirmed case or as part of an outbreak investigation?

Yes No

Are you member of one of the listed groups?

Resident or worker in long term care home (may need investigation under) Visitor to a long-term care home Resident or worker in homeless shelter Farm worker Resident or worker in other congregate settings (shelters, group homes, supportive housing) International student that has passed your 14-day quarantine period Resident or worker in retirement home Self-identify as indigenous None of the above

Have you received a preliminary positive COVID-19 test result from a rapid antigen screening test?

Yes No

Have you been advised to get tested for COVID-19 through an exposure notification through COVID-19 App?

Yes No

Are you over the age of 70 and experiencing any of the following : delirium, unexplained or increased number of falls, acute functional decline, worsening chronic conditions?

Yes No

Do you require a COVID-19 test for International travel clearance?

Yes No

Date of Signature

Signature

320 College Street North

Durham, ON N0G 1R0

519-369-5330

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COVID-19 Testing Assessment Form