Self-Isolation Plan Questionnaire

Persons arriving to Prince Edward Island may be required to present a self-isolation plan. Be prepared to answer the following questions or complete the Self-Isolation for Travellers form.

Self-Isolation Plan

In which county will you be isolating?

• Kings
• Queens
• Prince

What is your isolation household type?

• Private
• Family Member
• Commercial (ie hotel, BNB, etc)
• Other (describe)

List information of all household members (i.e. living at the same address):

• First name:
• Last name:
• Date of birth (yyyy/mm/dd):

Contact phone number while in isolation:

Contact person name while in Isolation:

Isolation address (if different than home address):

Do you have transportation to your isolation premise?

• Yes
• No

Do you have enough prescriptions for 14 days of self-isolation?

• Yes
• No
• Not applicable

Do you have enough supplies for 14 days of self-isolation (food, cleaning supplies, etc)?

• Yes
• No

Do you have local support (childcare, dog walk, etc) for 14 days of self-isolation?

• Yes
• No
• Not applicable

Do you have oudoor plans? If so please describe.

Are there any other details about your self-isolation plan we should know?