COVID-19 Case and Contact Information Form

Self-isolation is required for:

People who test positive for COVID-19
People who are awaiting COVID-19 test results
People who are close contacts of a COVID-19 case. If you are a close contact of a COVID-19 case, you must self-isolate for the entire monitoring period, even if you test negative

Self-isolation is required for anyone who is positive or presumed to be COVID-19 postive. Self-isolation means staying at home, except if you need urgent medical care. Do not go to work, school or public areas (such as stores, shopping malls, restaurants and places of worship). To learn more about self-isolation.
See BCCDC - Self Isolation.

Will you be able to self-isolate? *

Yes No

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

If yes, please fill out the fields below: *

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

Daycare/Preschool/Schools

Workplace

If yes, please fill out the fields below: *

Employer / Business Name *

Job Title *

Workplace Address *

(If unknown please indicate at least
the street name or city)

Department

(i.e. Population Public Health)

Date Last Visited *

Date End

Less than two meters

If yes, please fill out the fields below: *

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

Section 4: Household Contacts

Household Residents and Visitors *

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

First Name *

Last Name *

Relationship

Date of Birth

Phone Number

Date of Last Contact

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

Notifications within 14 days *

In the 14 days before you experienced COVID-19 symptoms, did you receive a verbal or written notification from Public Health, or anyone else stating:

you may have been exposed to someone with COVID-19 (i.e. from a worksite, gym, school or social gathering)
you were exposed to a known cluster or outbreak (i.e. from a worksite, gym, school or social gathering)

Yes No

Please note this form is not supported on Microsoft Internet Explorer.

Section 1: Personal Identifiers and Other Info

Personal Identifiers

⚠ The BC PHN you entered is not valid. Please re-confirm your PHN number before proceeding

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 *

⚠ The departure date cannot be greater than the date returned

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 *