New Brunswick Questionnaire 12785

This information we are collecting is for official government purposes and will be treated as confidential information Reset
Date of Month Day Year Time (24 hr) Licence plate Driver’s licence Commercial
entry
Passenger
Province of residency  NB   PEI   NS   NL   ONT   AB   PQ   Other
Travel Where are you arriving from? (City, Camp, Workplace, etc.) Destination in NB (Address) Length of stay
info

Reason / Nature for travel

 Custody Moving to NB NB Resident: Coming Home
Drive through to other location Work Related: NB Resident NB Resident: Daily Commute
 Compassionate Work Related: Non-NB Resident NB Resident: Longer Commute NB
Other: Please State Reason  Medical Resident: Returning from Away

Indentification Individual 1 Individual 2 Individual 3

Name - First / Last
Address

Telephone number
Date of birth
Required to self-isolate  Yes   No  Yes   No  Yes   No
Address of self-isolation

Screening questions
Have you been outside the country in the last 14 days?  Yes   No
Do you have two or more of the following symptoms:  Yes   No
* Fever or feeling feverish such as warm/chills, new or worsening cough, sore throat, runny nose, headache,
diarrhea, new onset fatigue, new onset muscle aches, loss of taste or smell?
Have you been in contact with anyone, including your family or direct social network, that has been sick with  Yes   No
any of these symptoms?
Have you been in contact with a known case of COVID-19, or have been in a setting (ie work camp) where  Yes   No
cases have been identified?
Has anyone in your family or direct social network been sick with any of these symptoms?  Yes   No
OFFICER USE ONLY  Do you understand that, unless exempted, you are ordered to self isolate for 14 days and  Yes   No
that a government official may follow up with you by phone or in person to confirm that you are doing so?
Violation if ordered is an offence.    Ordered to self-isolate and provided handout.
Do you have any questions?

Entry point
Land  Aulac  Baker Lake  Campbellton    Bayfield  Matapedia  Edmundston  Tidnish Road
Air   Fredericton Airport (YFC)    Saint John Airport (YSJ)  Moncton Airport (YQM)
Flight Number/Airline:
Where did the flight originate from? Montreal  Toronto  Arrival Time:
Sea Port Vessel Arrival
information time
Other
Allowed  Yes
entry No  If No: state reason

OFFICER USE ONLY  Officer / Agent Information

Government Staff Name Agency
Government Staff Date of Completion
Signature (DD/MM/YYYY)