Self-Reporting Form

Main

 
 
 
 
 
 
 
 
 
 
Sex
 

Ministry of Health Related

 
 
What is the reason for reporting? <span style="color:blue">(Check <strong>ALL</strong> that apply)</span>





 
 
Do you have any of the existing conditions? <span style="color:blue">(Check <strong>ALL</strong> that apply)</span>







 

Symptoms

 
Do you present any of the following <strong>primary</strong> signs and symptoms? <span style="color:blue">(Check <strong>ALL</strong> that apply)</span>



 
Do you present any of the following <strong>other</strong> signs and symptoms? <span style="color:blue">(Check <strong>ALL</strong> that apply)</span>







 
 

Travel and Contact

 
 
Did you engage in any international travel?
 
 
 
 
 
Did you have contact with any person who is under investigation for COVID-19?

 
Did you have contact with any person with a laboratory-confirmed case of COVID-19?

 
 
 
 

Consent Agreement

The purpose of this form is to obtain your voluntary consent to participate in the Ministry of Health's (MOH) COVID19 information gathering. The goal of the MOH's Self-Reporting Form is to get an accurate assessment of COVID19 related information in our community and to have more information to make informed decisions necessary to contain community spread.

Staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate use and protection of your information.

By agreeing to the consent section of this Form, you have agreed that you have given your informed consent to the collection, use for the purposes of analysis and that the MOH may contact you as necessary for follow up.

If you do not wish to take part in this information gathering activity, you can still call the MOH dedicated hotline at 0-800-MOH-CARE (0-800-664-2273).

 

Agree

 
<strong style="color:blue">I Agree </strong>