Adult participant: Name (please print) _________________________________________________________________
Date: _____________________

 

Main address of residence (in Quebec or outside Quebec)

___________________________________________________________________________________________________

Address (civic n˚,street)                                                                    City                                                                       Postal code                                 Province
Follow-up, secondary or stay address (e.g .: rental house, resident outside Quebec, etc.)

___________________________________________________________________________________________________

Address (n˚civique, street)                                                                City                                                                       Postal code                                 Province

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Indicate the period when we can reach you at this address. Start date: ________________ End date: __________________
                                                                                                                                                                        (yyyy / mm / dd)                          (yyyy / mm / dd)
Communications

Telephone (residential): ___________________ Telephone (cell) ______________________ Email: ________________________

 

During the past 14 days, have you had one or more of the symptoms related to COVID-19?
YES (specify in the list below)                                   NO

 

o Fever                                             o Sore throat                                    o Conjunctivitis
o Chill                                              o Difficulty swallowing                       o Headache
o Cough                                           o Runny nose *                                 o Nausea
o Dry/hoarse cough                          o Congested nose *                           o Vomiting
o Shortness of breath                         o Loss of taste or smell                        o Diarrhea

o Stomach pain                                 o Muscle pain                                   o Extreme fatigue

* (outside of the usual)

Did you have close (less than 2 meters) and prolonged (more than 15 minutes in a row) contact with a person
affected by COVID-19 in the last 14 days?                   YES                    I don't know                      NO

 

Think about where you have:
• slept outside your main residence
• been a customer
• worked or studied outside your main residence
• been visiting as part of your social activities

 

Flight/Air Travel
Have you had close and prolonged contact (within 2 meters, for more than 15 minutes) in an airplane flight?

                                                                               YES                    I don't know                       NO

 

Signature of the participant: _____________________________________________________________

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