COVID-19 Declaration Form

Version française

Voluntarily declaring that you have tested positive for COVID-19 will help limit the spread of the virus and protect the health and safety of the community. Completing a self-declaration form is not mandatory, but is strongly recommended.

The form will be sent to the COVID-19 Coordination Unit at Université Laval, and you will get an acknowledgment of receipt. The information you provide may be forwarded to a public health authority for contact tracing.

Your program director and teachers will be notified of your self-isolation start and end dates. If you have any assessments scheduled during this time, you must make arrangements with your program director and teachers.

The information provided will be securely logged and will be destroyed by April 30, 2021.

Once you have sent in your form, any request to access or modify the information should be emailed to covid19@ulaval.ca.

Identification

IDUL :

IN :

First name :

Last name :

Email :

Program of studies :

Are you a student athlete ?

NoYes

Situation

I hereby confirm that I tested positive for COVID-19 on the following date :

Date on which the screening test was done :

Did you have any symptoms ?

NonOui

Date of symptom onset :

Self-isolation start date, as prescribed by public health authorities :

Self-isolation end date, as prescribed by public health authorities :

Do you have any in-person courses or research activities this semester?

NoYes

If you have in-person courses, please indicate the most recent date you attended the class and the course number :

Course number :

If you have lab activities, please indicate when you were last there and the lab number :

If you have lab activities, please specify the lab room number :