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STD Form for COVID-19
Plan Member
Confirmation of Illness Form
Please only complete this form if your absence is due to symptoms of CO
VID-19 and you're pending
test results, or if you have a clinical diagnosis of COVID-19.
In recognition of the increasing pressure on our medical clinics and hospitals due to the COVID-19 pandemic, we
will not, at the outset, require an Attending Physician’s Statement as part of your disability claim submission if
your absence is due to COVID-19 symptoms, or a clinical diagnosis of the virus. This is a time limited exception
as we move through the current situation.
In the absence of an Attending Physician’s Statement, we require confirmation of your symptoms, your test
results, and any medical treatment you may have received for your condition. Accordingly, please complete
and sign this form and return it with your Employee Package, which you also need to complete.
1. Please
confirm:
2. Please indicate the symptoms associated with
yo
ur illness:
Fever Decreased appetite
Cough Runny nose
Fatigue Nausea
Muscle aches Vomiting
Sore throat Headache
Shortness of breath
Other
(
d
d/mm/yyyy)
3. Do you
have
an
y other health problems that might affect your recovery (e.g. diabetes, heart disease, respiratory
illness)?
STD Form for COVID-19
Policy number
:
Plan Member Name:
Date symptoms first appeared
:
First
day absent from work:
Certificate Number:
Plan Sponsor Name:
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
7. Any other details relating to your illness you'd like us to know:
Phone #: Cell #:
Date:
Name:
Signature:
STD Form for COVID-19
4. A) D
ate of medical consultation relating to COVID-19:
(dd/mm/yy)
B) Who was the medical consultation with (e.g.: physician/clinic/hospital/Public Health authority)?
(dd/mm/yyyy)
When do
you expect the quarantine to
end?
When are you next seeing your physician?
When do you expect to return to work?
5. A) Date of COVID-19 test:
B) Name, ad
dress and
p
hone number
of
facility
where
test
conducted.
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
C) Test result:
Attach test results if available.
Positive
Negative
Pending - if pending, date expected:
6. Have you been instructed to quarantine?
Yes, as of this date:
No
Can you work from home?
Yes
No
I certify that the statements in this form are true and complete and understand that further information may be
required to validate my claim.
For more information on the novel coronavirus, go to the Public Health Agency of Canada’s website at
https://www.canada.ca/en/public-health.html
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