Region of Waterloo Form

Required fields are marked with asterisks (*)

This form is for reporting suspect or confirmed cases of COVID-19 and other respiratory illnesses in high-risk settings, including long-term care homes, retirement homes, congregate living settings and shelters. Once submitted, the Region of Waterloo Public Health will follow up based on the level of priority. To report lab confirmed influenza call 519-575-4400 for the Service First Call Centre.

Submit this form daily BEFORE 1 p.m., even if waiting for further information or test results. This will ensure timely assessment and follow-up. Information received by the facility after 1 p.m. can be submitted to Public Health the following day.

Surveillance and Reporting

  • The following form can be used for:
    • Reporting symptomatic residents who are suspect cases of COVID-19 or other respiratory illnesses
    • Reporting COVID-19 positive molecular test (PCR) or RAT results in residents
    • Reporting results from Respiratory Virus testing in residents
    • Reporting COVID-19 Virus and Respiratory Viruses or RAT results in staff ONLY when your facility is currently in a confirmed outbreak.
      • If you have multiple individuals to report, complete the Respiratory Activity Line List (RALL) and submit it through this web-reporting form.
      • If you do not already have a RALL, request one by emailing
    • Requesting courier pick up of swabs.
  • You will receive an email confirmation after submitting this form, which includes some further instructions. Public Health will then follow up by phone based on level of priority.
  • Please only submit this form once per day and ensure the information entered is accurate.

Isolation and Additional Practices

  • All symptomatic residents must be promptly isolated and placed on Droplet and Contact Precautions with applicable signage.
    • Isolate the roommates of the symptomatic resident while confirmatory testing is pending
  • Ill staff must be excluded from work until a negative PCR COVID-19 result is received and they are afebrile with symptoms resolving for 24 hours (48 hours for GI symptoms).
  • As per facility policy and Ministry guidelines, staff unimmunized for influenza will be excluded from work in the event of an influenza outbreak if they refuse antiviral medication
  • Staff results that are negative must be reported to the facility by staff, as Public Health will not disclose this information.
  • Where possible, staff should be tested at the facility. Staff unable to be tested at the facility should seek testing at a community lab or pharmacy and reference the outbreak number provided to the facility. Refer to COVID-19 testing locations and clinical assessment centres to search for local testing locations.


  • For COVID-19: PCR testing is indicated for any symptomatic staff or residents. For a list of symptoms, refer to the MOHLTC COVID-19 Reference Document for Symptoms
    • Rapid antigen tests (RATs) should not be used for symptomatic residents and staff of LTCH or RH facilities
    • If RATs are used, parallel molecular testing should be done to confirm results
    • Report all test results (PCR and RAT) using this web form.
  • For Influenza and ARI: “COVID-19 Virus and Respiratory Viruses” should be selected on the lab requisition for residents and staff.
    • The first 4 swabs should be completed on residents (not staff) to receive the full multiplex respiratory panel.
    • After the first 4 outbreak samples, subsequent specimens will be tested for COVID-19, Influenza A&B, and RSV only.
Type of Facility
Current Outbreak Status
Are you reporting on a weekday or weekend/Statutory holidays
Are you reporting a new positive case?

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