Name *

First Name

Last Name

Do you have symptoms of cough, fever/high temperature (38° C or above), difficulty breathing, loss or change in your sense of smell or taste now or in the past 14 days? *

Yes

No

Have you been diagnosed with confirmed or suspected COVID-19 infection in the past 14 days? *

Yes

No

Are you awaiting the results of a COVID-19 test? *

Yes

No

In the past 14 days, have you been in contact with a person who is a confirmed or suspected case of COVID-19? *

Yes

No

Have you been advised to self-isolate at this time? *

Yes

No