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|
|DESTINATION ADDRESS||HOME ADDRESS||DATE TELEPHONE/TELEGRAPH NOTICE WAS GIVEN|
|METHOD OF ARRIVAL||PORT OF DEPARTURE||PORT OF ARRIVAL||DATE 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 days; and
(b) you sign the undertaking prescribed hereunder.
Signature of quarantine officer
SECTION C — UNDERTAKING TO REPORT AND UNDERGO SURVEILLANCE
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. days.
Signed this day of. 19
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