COVID-19 Symptom reporting form 

Bloc formulaire

This questionnaire aims to screen workers before entering their workplace to exclude those who are symptomatic and who have not had contact with a known case of COVID-19 already followed by public health authorities.

The questionnaire is intended to be completed by employees themselves on their workplace (other than health care facilities) to ensure the rapid removal of workers potentially infected with COVID-19 and to prevent its transmission to others in the workplace.

Employees with positive answers in their questionnaires should call 1 877 644 4545 or 811 to receive instructions (alternatively, check www.quebec.ca(link is external) for local phone numbers). When calling, the person should specify that he/she is a worker.


Anyone present at the site must fill out this form every day before the start of their working day.


Update February 1, 2021 - Version 5



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