Dominica Health Questionaire

First Name

Middle Name

Last Name

Email

ID Type

ID Number

Date of Birth

Gender

Male

Female

House/Apt. #

Street Number

State

Zipcode

Country

Local Address (in Dominica) Hotel/Accommodation/Apt. #/House #

Village

Parish

Health District

Phone Number

Occupation

Nationality

Date of Arrival

Time of Arrival

Flight No.

Place of Embarkation

Date of Embarkation

4. Please list the airports that you will be travelling to including layovers

Airport

Delete

Add Layover

5. Please list the countries visited within the last 21 days(This includes the country you are currently in)

Country

Delete

Add Country

6. Have you been in contact with someone who was diagnosed with COVID-19 within the last 14 days?

Have not been with an infected person

Was with a possible infected person

Spent significant time with an infected person

7. Do you presently have a cold, fever or cough?

Yes

No

8. Do you have a high tempreture or fever - hot to touch on your chest or back?

Yes

No

9. Have you started continuous dry coughing repeatedly recently?

Yes

No

10. Are you incredibly tired or fatigued?

Yes

No

11. Are you coughing up sputum, thick phlegm or mucus from your lungs?

Yes

No

12. Do you have shortness of breath?

Yes

No

13. Do you suffer from a major medical issue, like heart disease, diabetes, asthma, chronic bronchitis, COPD, cancer or an autoimmune disorder?

No major medical issues

One major medical issues like diabetes or a heart condition

Multiple medical issues or a serious condition such as Cancer or COPD

14. Do you smoke?

I don’t smoke

I have smoked at least 100 cigarettes in my life

I smoke at least once a week

15. Have you frequented higher traffic public spaces(like shopping centers, restaurants) within the last month?

None

Some

Multiple Times

16. How often do you sanitize or wash your hands with soap and water?

Wash hands frequently, 5 or more times a day

Wash hands 2 or 3 times a day

Not very often

17. Are you praticing physical distancing and wearing a face-mask?

Yes

No

18. Have you taken any test for COVID-19?

Yes

No (If no, please skip questions 19-22)

19. The date, swab was taken

20. PCR-test result

COVID-19 - detected

COVID-19 - not detected

21. Rapid diagnostic test(RDT) results (Optional)

IgG positive

IgM positive

Non-reactive

22. Upload test results

Please only upload jpg, png or pdf, any other file types will cause your submission to fail.

Terms and Conditions

By completing and submitting this questionnaire, you are agreeing to comply with and be bound by the following terms and conditions -
All travelers are required –

All travelers are required –
1. to sanitize their hands at sanitization stations as directed;
2. to undergo a health assessment to include a temperature check;
3. to undertake a Rapid Diagnostic Test.
4. to wear mask at all times.

A. Upon clearance from the port, travelers from countries within the CARICOM Travel Bubble must adhere to the following:
1. Submit to scheduled and unscheduled checks by medical professionals
B. Upon clearance from the port, travelers from low risk countries must adhere to the following:
1. Travelers will be monitored for seven (7) days at their place of residence
2. All travelers must submit to scheduled and unscheduled checks by medical professionals.
C. Upon clearance from the port, travelers from medium risk countries must adhere to the following:
1. Traveler will be monitored for 14-days at their place of residence
2. Optional to 14- day monitoring, a PCR test can be done on day 5. If the result is negative, there will be no further monitoring at their place of residence.
3. All travelers must submit to scheduled and unscheduled checks by medical professionals.
D. Travelers from high risk countries must comply to the following:
1. Traveller will proceed to secondary screening area
2. A Rapid Diagnostic Test will be administered on arrival

i. If Rapid Test is positive, a PCR test will be administered immediately and traveller will await the results in a Government approved facility (at travellers expense).

ii. If Rapid Test is negative, traveller will be transported to mandatory quarantine at a Government operated quarantine facility or Government-certified private property for a minimum of 5 days.

3. All travelers must submit to scheduled and unscheduled checks by medical professionals.
4. A PCR test will be administrated to the traveller on Day 5 after arrival.

All costs incurred during the period of quarantine/treatment including PCR test must be paid prior to discharge.

Penalties will be applied for giving false information in the questionnaire and disregarding the quarantine process.

Staff

Bob Nilson

Nick Larson

Deon Hubert

Ella Wong

Customers

Lara Kunis

Ernie Kyllonen

Lisa Stone

Deon Portalatin

Irina Savikova

Maria Gomez

General

System

General Settings

System Settings