Dominica Health Questionnaire
Thank you for taking the time to fill out this Covid19 Pre-Screening Questionnaire
1. Incorrect entries will be highlighted in red with explanation beneath
2. Correct Entries will be highlighted in green
3. Fields with '*' are mandatory. You will not be able to submit the form if they are left blank
4. Please check your JunkMail or Spam folder and whitelist or mark emails from this address as not spam.
5. Use the QU Code received after successful submission of this form, as a reference for further information.
6. Please Make every effort to type your email address correctly as this is your main point of contact.
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Please verify questionnaire information before proceeding.