All personal health information will be kept confidential in accordance with the Personal Health Information Act (PHIA). This form should only be submitted for individuals who are on site. If you  are not on site, please connect with your instructor, advisor or supervisor for further details and follow Public Health guidance.

Information of individual with positive COVID-19 test result

What best describes the individual
Select all that apply
Has the individual had symptoms of COVID-19?
Positive test results
Please indicate the test date and type for each positive COVID-19 test result the individual has received.
Date of test Type of test Operations

On campus exposures

Was the individual on campus during the period of communicability?
Period of communicability is considered to begin two days before symptom onset (or two days before test date if asymptomatic) and continues for 10 days after that date.
Times on campus
Please provide the date, time of arrival and time of departure for each location the individual was at for more than 10 minutes during the period of communicability.
Date Location (include building and room number) Time of arrival at location Time of departure from location Operations
Was a mask and/or PPE worn while on campus for all above period of communicability?
Did the individual have close contact with anyone on campus?
Can the individual identity all their close contacts?
Is the individual able to contact all their close contacts?

Notice Regarding Collection, Use, and Disclosure of Personal Health Information by the University

The personal information and personal health information is being collected under the authority of The University of Manitoba Act. The information provided will be used by the University for the purpose of managing health and safety processes in the University community. The personal information and personal health information will not be used or disclosed for other purposes, unless permitted by The Freedom of Information and Protection of Privacy Act (FIPPA) and/or The Personal Health Information Act (PHIA). If you have any questions about the collection of personal information and personal health information, contact the Access & Privacy Office (tel: 204-474-8339), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.