Provincial Health Screening Form

Your Name (required) *

Your Email (required) *

Your Port Pass Number or Appointment Confirmation ID# (required)

Have you traveled outside of Canada, including the United States, within the last 14 days?YesNo

Have you been identified as a close contact of a COVID-positive case by Public HealthYesNo

Have you been told to self-isolate by Public Health?YesNo

Date Questionnaire Completed? *