JeContribue - Inscription

Your contact details

First name

Last name

Telephone number

Home phone number

Cellular phone number

Email address

Postal code

Format: G1G 1G1

Do you have your Canadian citizenship? Yes No

Are you able to communicate in French? Yes No

Are you able to communicate in English? Yes No

To which group(s) do you wish to contribute? Vaccination COVID-19 ou antigrippale (masse, mobile ou traditionnelle)
Dépistage COVID-19 (Être membre d’un ordre professionnel ou un étudiant autorisé à effectuer ou à analyser des tests de dépistage)
Enquête COVID-19 (Habiletés à réaliser des enquêtes, professionnels de la santé, policiers, etc.)

Have you obtained or are you currently studying for a diploma in the health field? Yes No

Please state its title :

If a professional license is required, is it currently valid? Yes No

What is your practice number?

Work sector preference

If it is not possible to respond to your first choice, would you agree to work in another institution? Yes No

What is your availability? (Every other weekend is required for most positions in the health and social services network) Day
Evening
Night
Weekend

From what date are you available?

How many days a week are you available?

Do you agree to be in direct contact with patients who could potentially be affected by COVID-19? Yes No

During the past 14 days, have you been in the presence of someone with symptoms related to COVID-19? Yes No

Please choose a symptom Toux
Fièvre
Perte soudaine du goût ou de l'odorat sans congestion nasale
Difficultés respiratoires

Are you currently in voluntary isolation? Yes No

Are you currently in mandatory isolation? Yes No

Have you been back from your trip for less than 14 days? Yes No

Professionals qualified to vaccinate and mix substances:

✓ Physician
✓ Nurse (external)
✓ Respiratory therapist
✓ Midwife
✓ Auxiliary nurse
✓ Pharmacist
✓ Medical resident

Professionals authorized to vaccinate and mix substances by Order No. 2020-099 and Order No. 2021-005 whose training leads to the profession of:

✓ Acupuncturist
✓ Audiologist
✓ Hearing aid practitioner
✓ Chiropractor
✓ Dentist
✓ Denturist
✓ Dietitian or nutritionist
✓ Occupational therapist
✓ Dental hygienist
✓ Veterinarian
✓ Dispensing optician
✓ Optometrist
✓ Speech therapist
✓ Physiotherapist
✓ Podiatrist
✓ Ambulance technician
✓ Medical technologist
✓ Medical electrophysiology technologist
✓ Medical imaging technologist
✓ Physiotherapy technologist
✓ Dental prosthetic and device technologist

Students authorized to vaccinate and mix substances by Order No. 2020-099 and Order No. 2021-005 whose training leads to the profession of:

✓ Physician (1st year completed)
✓ Respiratory therapist (3rd year)
✓ Midwife (3rd and 4th year)
✓ Auxiliary nurse (Competencies 1 to 9 completed)
✓ Pharmacist (3rd and 4th year)
✓ Ambulance technician (3rd year)

Professionals authorized to vaccinate and mix substances by Order No. 2021- 022 whose training leads to the profession of:

✓ Radiation oncology technician
✓ Orthopedic orthotic and prosthetic technologist
✓ Chemist
✓ Biochemist
✓ Clinical biochemist

Students authorized to vaccinate and mix substances by Order No. 2021-022 whose training leads to the profession of:

✓ Acupuncturist
✓ Audiologist
✓ Hearing aid practitioner
✓ Chiropractor
✓ Dentist
✓ Denturist
✓ Dietitian or nutritionist
✓ Occupational therapist
✓ Dental hygienist
✓ Veterinarian
✓ Dispensing optician
✓ Optometrist
✓ Speech therapist
✓ Physiotherapist
✓ Podiatrist
✓ Medical technologist
✓ Medical electrophysiology technologist
✓ Medical imaging technologist
✓ Physiotherapy technologist
✓ Dental prosthetic and device technologist
✓ Radiation oncology technician
✓ Orthopedic orthotic and prosthetic technologist
✓ Chemist
✓ Biochemist
✓ Clinical biochemist
✓ Nurse (1st year completed)

Non-professionals authorized to vaccinate and mix substances by Order No. 2021-027:

✓ Kinesiologist
✓ Clinical perfusionist
✓ Medical laboratory technician
✓ Animal health technician
✓ Embalmer
✓ Sport therapist
✓ Student enrolled in at least the second term of the next-to-last year of study in animal health, thanatology, kinesiology or sport therapy

Non-professionals authorized to mix substances by Order No. 2021-027:

Holders of an undergraduate degree issued by a university in Québec in:
✓ Biology
✓ Medical biology
✓ Microbiology
✓ Neuroscience
✓ Biomedical science
✓ Pharmaceutical or biopharmaceutical science
✓ Student enrolled in at least the second term of the next-to-last year of study of a university program in biology, medical biology, microbiology, neuroscience, biomedical science, or pharmaceutical or biopharmaceutical science

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