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Letter of Required Support Eng PDF

The document is a letter of required support for an exemption from COVID-19 travel restrictions and/or limited release from federal quarantine on compassionate grounds. It requires information about the traveler such as their name and dates of travel. It also requires a licensed health care professional to attest the purpose of travel/release from quarantine is to attend to a critically ill Canadian citizen or provide care to a Canadian citizen who requires support and has a medical reason. The health care professional must provide their name, profession, unique identifier, work address, contact information and signature to confirm the information provided is true.

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314 views2 pages

Letter of Required Support Eng PDF

The document is a letter of required support for an exemption from COVID-19 travel restrictions and/or limited release from federal quarantine on compassionate grounds. It requires information about the traveler such as their name and dates of travel. It also requires a licensed health care professional to attest the purpose of travel/release from quarantine is to attend to a critically ill Canadian citizen or provide care to a Canadian citizen who requires support and has a medical reason. The health care professional must provide their name, profession, unique identifier, work address, contact information and signature to confirm the information provided is true.

Uploaded by

mohamedwaly
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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"Required fields are marked with an asterisk (*).

" Protected B when completed

Letter of Required Support


Request for Exemption on Compassionate Grounds:
COVID-19 Federal Travel Restrictions and/or Limited Release from Federal
Quarantine

Traveller Legal Name*: First / Middle / Last Name (hereinafter “Traveller”)


In response to the risks posed by the outbreak of COVID-19, a person entering Canada is subject
to any order made under section 58 of the federal Quarantine Act (S.C. 2005, c. 20) prohibiting
the entry into Canada from the United States or a country other than the United States, and
requiring all persons who enter Canada to quarantine for a period of at least 14 days beginning
on the day on which the person enters Canada, subject to certain limited exemptions.
I, being a licensed health care professional, attest that the Traveller’s purpose for entering Canada
and/or temporarily leaving quarantine is:

To attend to the death of or provide support to a Canadian citizen, permanent


resident, temporary resident, protected person or a person registered as an Indian
under the Indian Act who is residing in Canada and who I deem to be critically ill.*

To provide care for a Canadian citizen, permanent resident, temporary resident,


protected person or a person registered as an Indian under the Indian Act who is
residing in Canada and who I deem to have a medical reason as to why they require
support.*
Date(s) the Traveller’s purpose above is relevant*: to
Legal Name of Signatory*: First / Middle / Last Name of signatory
Profession of Signatory*:

Other:
Signatory unique identifier (e.g. MINC)*:
Work address*: Street Number Street Name City Name Province or Territory

Work contact information: (email)*


(telephone)* (XXX)XXX-XXXX
Providing false information: It is an offence under the Quarantine Act to provide a false or
misleading statement. Alternatively, you could also be issued a fine under the Contraventions
Act.
2 | Letter of Required Support Request for Exemption on Compassionate Grounds Protected B when completed

I confirm that the information I have provided above is true.*


Signature*: Date of signature*:

Privacy notice: The personal information provided is governed in accordance with the Privacy Act. We collect the
information needed for the Public Health Agency of Canada (PHAC) to administer and enforce the Minimizing the
Risk of Exposure to COVID-19 in Canada Order (Mandatory Isolation), the Quarantine Program (authorized under
the Quarantine Act), and for programs or activities of PHAC authorized by the Quarantine Act and/or Department
of Health Act. This information is collected and used by PHAC in relation to the Traveller’s application for
“Exemption on Compassionate Grounds of COVID-19 Travel Restrictions” and/or “Limited Release from
Quarantine” and may also be disclosed to the following entities: law enforcement (including, in particular, peace
officers), other government institutions, as well as provincial, territorial, municipal governments or organizations
as well as their institutions. In limited and specific circumstances, personal information may be used and disclosed
without consent in accordance with subsection 8(2) of the Privacy Act.

Your rights under the Privacy Act: In addition to protecting your personal information, the Privacy Act gives you
the right to request access to and request correction of your personal information. For more information about
these rights, or about our privacy practices, please contact the PHAC Privacy Coordinator: phac.privacy-
[email protected]. You also have the right to file a complaint with the Privacy Commissioner of Canada if
you think your personal information has been handled improperly.

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