COVID-19 Case and Contact Information Form



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Section 1: Personal Identifiers and Other Info

Personal Identifiers




(Found on your BC Services Card,
or other Provincial Health Service Card)

   



(As shown on government issued ID)





               





                       
Self-Isolation



               



Section 2: Symptoms

Symptoms at the Time of Testing






                       


                       


                       


                       

                       


                       


                       


                       


                       


                       


                       


                       


                       


                       


                       


                       


                       


                       


                       



Section 3: COVID-19 Exposure to Others

Exposure Settings










Accessed Health Care Services *


               
Large Social Gatherings *


               
Intimacy


                       
Daycare/Preschool/Schools


               
Workplace


               

Less than two meters


                       

Section 4: Household Contacts

Household Residents and Visitors *


   



Section 5: Where you may have gotten COVID-19 from

Notifications within 14 days *

               

Contact with a positive COVID-19 case within 14 days *


                       

Community Settings *


               

Large Gatherings within 14 Days *


               

Travel *


               
Thank you for completing this form and helping to reduce transmission of COVID-19 in our communities

PLEASE CHECK EACH STATEMENT TO ACKNOWLEDGE YOU HAVE READ OUR SITE POLICIES, AND THEN CLICK SUBMIT FORM TO FRASER HEALTH *