Yes No
Health information
Do you have any known exposure to COVID19?
Are you symptomatic (fever, short of breath, cough)? Yes No
Agreement to self-isolation measures
Do you agree to the following self-isolation measures outside of working hours?
Yes No Initials:
Yes No Initials:
Yes No Initials:
1. Not visiting any local/retail stores:
2. Avoiding all gatherings/events:
3. Remaining isolated in room/house/hotel:
4. Maintaining social distancing (two meters): Yes No Initials:
P.O. Box 1000, Stn. 1000
Iqaluit, Nunavut X0A 0H0
C.P. Box 1000, Succursale 1000
Iqaluit, Nunavut X0A 0H0
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! Monitor closely for symptoms and immediately call the health centre if you develop symptoms.
Instructions for completing this form
To ensure that requests can be processed in a timely fashion, please ensure that all parts of this form are completed as
instructed. Incomplete forms may result in a delay in processing. Important: this form must be submitted within 7 days of
your travel to Nunavut. Please allow up to 2 business days for processing. Note that you have to receive a signed CPHO
travel authorization letter to board your flight. This letter is valid for 7 days after receipt.
Once approved, you will receive a travel agreement for contact tracing and enforcement purposes that must be signed.
Declaration
Please read carefully. By signing this application, I declare the following: the information in this application and in any attachment is
true and accurate; I understand that if I choose to complete and submit this application electronically it will be equivalent to an
electronic signature, and will be treated in the same manner as if I had signed and submitted it through other means.
Providing misleading or false information in response to these questions or to the office of the Chief Public Health Officer constitutes
a breach of the Travel Restriction Order and can be punishable by a $575 fine.
Printed employee name:
Employee signature:
Categories of exemptions
The following definitions are meant as a general guideline, and must be accompanied by a rationale as to why the request for
exemption is critical. No position is deemed critical by nature of its job title alone.
Government of Nunavut exempted workers: a Government of Nunavut-employed worker who is required urgently in the territory because his or
her work is essential.
Non-GN Essential Trades: A Red Seal or Red Seal-Equivalent tradesperson who is required to perform essential work in the territory. "Red Seal-
Equivalent" means a worker who is on Red Seal Apprenticeship Track and who been prevented from taking the Red Seal exam due to COVID-19.
Non-GN Exempted Workers: A worker, employed by an employer other than the Government of Nunavut, who is required urgently in the territory
because his or her work and/or skills are considered essential and unfillable by another worker in the territory.
Physicians: Medical doctors who are required urgently in the territory.
Compassionate: Individuals who require urgent entry to the territory in order to attend to a sick immediate family member; to visit with a dying
immediate family member; or attend the funeral of an immediate family member.
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signature
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