October 28, 2021 Version 2.3 Page 1 of 2

Selection Lists for AIA Referral Form Please use value(s) from the following selection lists when completing the Referral for Alternate Isolation Accommodation(s).

Home Community • Berens River• Birdtail Sioux• Black River• Bloodvein• Brochet (Barren Lands)• Brokenhead• Buffalo Point• Crane River (O-Chi-Chak-Ko-Sipi)• Cross Lake• Dakota Plains• Dakota Tipi• Dauphin River• Easterville (Chemawawin)• Ebb & Flow• Fairford (Pinaymootang)• Fisher River• Fort Alexander (Sagkeeng)• Gambler• Garden Hill• Gillam/Bird (Fox Lake)• God's Lake Narrows• God’s River (Manto Sipi)

• Grand Rapids (Misipawistik)• Hollow Water• Ilford (War Lake)• Indian Birch (Wuskwi Sipikh)• Jackhead (Kinonjeoshtegon)• Keeseekoowenin• Lac Brochet (Northlands)• Lake Manitoba• Lake St Martin• Little Grand Rapids• Little Saskatchewan• Long Plain• Marcel Colomb• Moose Lake (Mosakahiken)• Nelson House (Nisichawayasihk)• Norway House• Nunavut• Oak Lake Sioux (Canupawakpa)• Opaskwayak• Oxford House (Bunibonibee)• Pauingassi• Peguis

• Pine Creek• Poplar River• Pukatawagan (Mathias Colomb)• Red Sucker Lake• Rolling River• Roseau River• St. Theresa Point• Sandy Bay• Sapotaweyak• Saskatchewan• Shamattawa• Sioux Valley (Dakota Nation)• Skownan• South Indian Lake (O-Pipon-Na-Piwin)• Split Lake (Tataskweyak)• St. Theresa Point• Swan Lake• Tadoule Lake (Sayisi Dene)• Tootinaowaziibeeng• Wasagamack• Waywayseecappo• York Landing

Racial, Ethnic or Indigenous Identity • African• Black• Chinese• Filipino• Latin American

• North American Indigenous – that is, First Nations, Metis or Inuit• South Asian• Southeast Asian• White• Other – provide details• Prefer not to answer

Service Delivery Organization • Interlake Eastern RHA (IERHA)• Northern Health Region (NHR)• Prairie Mountain Health (PMH)• Shared Health (SH)• Southern Health – Sante Sud (SH-SS)• Winnipeg Regional Health Authority (WRHA)• Addictions Foundation of Manitoba (AFM)• CancerCare Manitoba (CCMB)• First Nations Inuit Health Branch (FNIHB)• Indigenous Services Canada• Selkirk Mental Health Centre• Other Approved Referring SDO – provide details

Agency Referred From • Community• Occupational and Environmental Safety & Health (OESH)• Emergency Response Services (ERS)• Public Health Agency of Canada (PHAC)• Corrections• Cancer Care• Churchill Health Centre• Concordia Hospital• GGH• Health Links• HSC• HSC - Adult• HSC - Children's• HSC - Psych• HSC - Women's• SBH• SOGH• Supportive Housing (e.g. group home)• VGH• Virtual Covid-19 Outpatient Program (VCOP)• Other – provide details

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COVID-19 Symptoms – select all that apply • Fever• Dry cough• Tiredness• Muscle aches and pains• Sore throat• Diarrhea• Conjunctivitis• Headache• Loss of taste/smell• Rash of unknown cause• Other

Current Health Conditions – select all that apply • AMI• Arthritis• Asthma• Auto-immune disorder• Cancer• Cirrhosis• COPD• Dementia• Diabetes• Dialysis• Heart failure• Hypertension• IHD• Immunocompromised state• Kidney disease• Neurodegenerative disorder• Seizure disorder• Stroke• Transplant• Other