Quarantine Regulations

Version of the schedule from 2006-03-22 to 2006-12-11:


SCHEDULE I(s. 29)

Department of National Health and Welfare Medical Services Branch — Quarantine Service

Surveillance Notice and Undertaking To Report to a Medical Officer of Health

SECTION A — PERSON UNDERTAKING TO REPORT SERIAL NUMBER
FAMILY NAME (block letters) GIVEN NAMES SEX

M      F

OTHER PERSONS
DESTINATION ADDRESSHOME ADDRESS DATE TELEPHONE/TELEGRAPH NOTICE WAS GIVEN
METHOD OF ARRIVALPORT OF DEPARTURE PORT OF ARRIVALDATE OF ARRIVAL
(Airline and flight number or name of ship)
SECTION B — NOTICE OF SURVEILLANCE

You are permitted to proceed directly to your destination address if

(a) forthwith on arrival at your destination address you report to and place yourself under the surveillance of the medical officer of health for the area in which your destination is located for a period of blank line days; and

(b) you sign the undertaking prescribed hereunder.

blank line

Signature of quarantine officerblank line

blank line

SECTION C — UNDERTAKING TO REPORT AND UNDERGO SURVEILLANCE

blank line

I acknowledge receipt of and understand the Notice of Report and Surveillance and, on being permitted by a quarantine officer to proceed directly to my destination, I hereby undertake forthwith upon my arrival at my destination to report to and place myself under the surveillance of the medical officer of health for the area in which my destination is located for a period of.blank line days.

Signed this blank line day of. blank line19blank line

blank line

Signatureblank line

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