Declaration of symptoms and infections related to COVID-19
In order to avoid transmission of COVID-19, this form must be filled out by any member of the university community (student, member of staff, management and faculty) who meets one or more of the following conditions:

- Experiences one or more symptoms related to COVID-19 (according to the government’s website);
- Has received a POSITIVE diagnosis following a COVID-19 screening test;

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Select the statement that best describes your situation: *
*Individuals who experience symptoms related to COVID-19 should contact the Ministère de la Santé et des Services sociaux by phone, at 1-877-644-4545. Please indicate below any instructions you received (e.g.: I was told that may symptoms are not related to COVID-19 and I can return to work; I was told to take a COVID-19 screening test, etc.):
Other pertinent information related to your situation as described above (date when symptoms first appeared, date of diagnosis, date of beginning of isolation mandated by Public Health, countries visited and return date, etc.): *
Campus attendance
When was the last time you were on Campus? *
Were you on campus in the past 48 hours (prior to the onset of the symptoms or after being in contact with an infected person)? *
If yes, please indicate all areas where you were and the times when you were there, along with the names of any individuals with whom you had close contact (i.e.: within less than two metres). In addition, for each incidence of close contact indicated, please specify whether you were wearing a procedural mask or no mask (e.g.: Pavilion A hall at 7:45 a.m., close contact with Yannick XYZ in Lab A 0000 at 8:00 a.m., I was wearing a procedural mask, etc.) :
Last name *
First name *
Permanent code (students)/Identification number (employees) : *
Position : *
Telephone number *
E-mail address : *
Department, Service, Centre or Program, as applicable : *
If you are a staff member, please give the name of your immediate supervisor?
The sole purpose of these questions is to enable ÉTS to work in collaboration with Public Health to ensure the protection of the public.

The responses to these questions are confidential in nature, and ÉTS will undertake all necessary measures to guarantee their confidentiality.
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