MINISTRY OF HEALTH - GRENADA
INCOMING PASSENGER HOME QUARANTINE APPLICATION
(P) +1 (473) 440-2649 / 2806 / 2846 / 3485 I (F) +1 (473) 440-4127 / 6848 I (E) firstname.lastname@example.org
I, Mr /Ms. D.O.B: Age: Sex: Arrival Date into Grenada: D.O.B: Passport N°: Flight N° if known: Seat N° if known: . Intended address in Grenada: Occupation: Mobile phone N°: Home phone N°: Name of Local Contact: Mobile N° of local Contact:
1. Location of proposed residence to be used:
2. Please state the number of persons in household:
3. Please state the Age(s) of persons in household:
4. What are the health conditions of the persons residing in the house:
Renal (Kidney) failure:
Cancer / lymphoma:
Please state any other non/respiratory illness:
5. I agree to be self-quarantine as per the conditions, advice and directives of the Chief Medical Officer or designate. In so doing I agree to download and install Grenada's COVID-19 App and follow the instructions regarding the proper and effective use of the App.
6. I will comply with all anti-coronavirus 2 (SARS-CoV- 2) / (COVID-19) precautionary measures, instructions of the Ministry of Health in-keeping with the rules conditions under which I am to be and remain self-quarantined.
7. I hereby declare that the details given above are true and correct to the best of my knowledge and belief and I undertake to inform concerned Health authorities through the COVID-19 Helplines; 538-4784, 458-4787, 438-4787 regarding any change therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for an offence or violation of Public Health Safety Laws and all applicable law(s) of Grenada.
8. I understand and agree with all conditions of self-quarantine and so further agree to INDEMNIFY AND NOT HOLD RESPONSIBLE the MINISTRY OF HEALTH
OR IT'S AGENTS, against all claims, liabilities, suits of any nature whatsoever arising out of, because or due to the quarantine of myself.
What should I do if I've been told to self-quarantine?
The following instructions are provided to assist you to safely care for yourself or others who are infected or potentially infected with COVID-19. View the instructions on https://www.facebook.com/HealthGrenada/ or
Your health care provider and public health staff will evaluate whether you can be safely cared for at home. If it is determined that you do not need to be hospitalized and can be isolated at home, you will be monitored by staff from your local health department. You should follow the prevention steps below until a the Chief Medical Officer (CMO) or designate says you can return to your normal activities.
Stay home except to get medical care.
You should restrict activities outside your home, except for getting medical care. Under NO circumstance should you go to work, school, supermarket, beach, church, gym or public areas. Avoid using public transportation, ride sharing, or taxis.
Separate yourself from other people and animals in your home.
People: As much as possible, you should stay in a specific room and away from other people in your home. Also, you should use a separate bathroom, if available. Animals: You should restrict contact with pets and other animals while you are sick with COVID-19, just like you would around other people. Although there have not been reports of pets or other animals becoming sick with COVID-19, it is still recommended that people with COVID-19 limit contact with animals until more information is known about the virus. When possible, have another member of your household care for your animals while you are sick. If you must care for your pet or be around animals while you are sick, wash your hands before and after you interact with pets and wear a facemask.
Call ahead before visiting your doctor.
If you have a medical appointment, call the health care provider prior to your appointment and tell them that you have or may have COVID-19. This will help the health care provider's office take steps to keep other people from getting infected or exposed. Ask your health care provider to call the local health department. Persons who are placed under active monitoring or facilitated self-monitoring should follow instructions provided by their local health department as appropriate. If you have a medical emergency and need to call (434), notify the dispatch personnel that you have, or are being evaluated for COVID-19. If possible, put on a facemask before emergency medical services arrive.
Take care of your mental health.
You might be feeling anxious, afraid, lonely or uncertain. Follow us on facebook for a list of helpful behavioral health resources, and a few tips for taking care of your emotional health while you're quarantined.
Wear a face mask.
You MUST wear a facemask when you are around other people (e.g., sharing a room or vehicle) or pets, and before you enter a health care provider's office. If you are not able to wear a facemask (for example, because it causes trouble breathing), then people who live with you SHOULD NOT stay in the same room with you, or they should wear a facemask if they enter your room_
Cover your coughs and sneezes.
Cover your mouth and nose with a tissue when you cough or sneeze. Throw used tissues in a lined trash can.
Clean your hands often.
Wash your hands often with soap and water for at least 20 seconds or clean your hands with an alcohol-based hand sanitizer that contains 60 to 95% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Soap and water should be used preferentially if hands are visibly dirty. Avoid touching your eyes, nose, and mouth with unwashed hands.
Clean all frequently-touch surfaces daily.
Clean all frequently-touch surfaces daily. These include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Also, clean any surfaces that may have blood, stool, or body fluids on them. Use a household cleaning spray or wipe, according to the label instructions. Labels contain instructions for safe and effective use of the cleaning product including precautions you should take when applying the product, such as wearing gloves and making sure you have good ventilation during use of the product.
Avoid sharing personal household items.
You should not share dishes, drinking glasses, cups, eating utensils, towels or bedding with other people or pets in your home. After using these items, they should be washed thoroughly with soap and water.
Monitor your symptoms.
Persons who are placed under active, facilitated or self-monitoring should follow instructions provided by the Ministry of Health as appropriate. Notify the MINISTRY OF HEALTH and seek prompt medical attention if your illness is worsening (e.g., difficulty breathing). COVID-19 Helplines; 538-4784, 458-4787, 438-4787.
Signature of Guardian if under 18yrs of age.