Quarantine Plan Template

14-Day Quarantine / Isolation Plan for (indicate your legal name)

Transportation

When I arrive at _________________ I plan to use _________________ to get to my place of

quarantine.

(your destination in Canada) (taxi or personal vehicle)

I will make no stops anywhere on my way to my quarantine location, and I will wear a mask or face

covering at all times. I will also sanitize my hands before entering the vehicle and after exiting the

vehicle.

Quarantine Location Details

I am prepared to spend 14-days of quarantine at the following location:

______________________________________________________________

During quarantine, my phone number will be :______________________________

I can be reached at this number in Canada.

I confirm that the above mentioned location place where I will spend the 14 days of my quarantine

(and more, if necessary) does not have any exposure to vulnerable people (65 years of age or older

or persons with underlying health problems).

I confirm that I have a private bedroom and a private bathroom that will not be shared with others.

Food and Personal Needs

During my quarantine period, I plan to supply myself with food and other necessities as described

below (please delete any that you will not use)

1.Online shopping and delivery to the door as follows: (indicate name of store and delivery service you have

identified)

_______________________________________________________________________________________

2.Catering service provided by my quarantine site with delivery to the door (incate name of catering service

and other relevant

details:_________________________________________________________________________________

_______________________________________________________________________________________

3. Food dropped off at the door by family and friends (provide a list of friends/family, with their addresses and

a means to contact them, who will help you get

food):__________________________________________________________________________________

_______________________________________________________________________________________

Health or Emergency Care

If I experience illness or symptoms of COVID-19, I will call the local health authorities at using the

following phone number __________________________

I will go to a screening centre, medical clinic, or hospital and comply with health measures of

wearing a mask or face covering as instructed by the authorities. Upon arrival, I will inform the staff

that I have travelled abroad.

Financial Resources

I have a credit card and Canadian currency that will allow me to cover the costs of transportation,

lodging, food, and health or emergency care, if necessary, to comply with the health measures in

effect upon arrival, during my period of quarantine, and during my stay in Canada.

Declaration

I agree to stay in the location where I will spend my quarantine, and comply with all the measures

above without going out to public places or having visitors.

Signature:______________________________

Name:__________________________________

Date of birth:_____________________________

Passport number:_________________________

NOTES:

____________________________________________________________