COVID-19 self-assessment questionnaire

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For all hearing participants attending a hearing in-person on Immigration and Refugee Board premises,​ you must complete the following self-assessment questionnaire:

  • 14 days prior to the day of your hearing; and
  • if you or anyone you live with displays any of the symptoms at question 4 at any time within 14 days the day of the hearing.
  1. Has a doctor, health care provider, or public health unit told you that you should be self-isolating (staying at home) today?

    2. Yes No

  2. Have you tested positive for COVID-19 in the past 14 days?

    3. Yes No

  3. ​Are you waiting for results of a COVID-19 test?

    4. Yes No

  4. ​​Have you or anyone you live with experienced any of the following symptoms in the last 14 days?

    5. New or worsening cough

    Yes No

    Shortness of breath

    Yes No

    Sore throat

    Yes No

    Runny nose, sneezing or nasal congestion (in absence of underlying reasons
    for symptoms such as seasonal allergies and post nasal drip)

    Yes No

    Hoarse voice

    Yes No

    Difficulty swallowing

    Yes No

    New smell or taste disorder(s)

    Yes No

    Nausea/vomiting, diarrhea, abdominal pain

    Yes No

    Unexplained fatigue/malaise

    Yes No

    Chills

    Yes No

    Headache

    Yes No

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  1. Have you travelled abroad or had close contact with anyone who has travelled in the past 14 days?

    2. Yes No

  2. Do you have a fever?

    3. Yes No

  3. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19 in the past 14 days?

    4. Yes, go to question 8 No

  4. Did you wear the required and/or recommended personal protective equipment according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19?

    5. Yes No

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If you answered “Yes” to any questions from 1 to 6, do not go to IRB. Contact the Division immediately. We will see if your hearing can be held virtually at the same date and time. If not, we will reschedule your hearing.

If you answered “Yes” to question 7 and “No” to question 8​, do not go to IRB. Contact​ the Division immediately. We will see if your hearing can be held virtually at the same date and time. If not, we will reschedule your hearing.​

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