Covid 19- form English / Covid 19

Surname of the person who made the reservation *

Your name *

I can be reached on telephone number *

E-mail address *

Date of the sailing trip *

Name of the sailing trip *

Muider Hardzeildagen

Volendam voor de Boeg

Rondje Amsterdam

Zondag onder Zeil

Do you have a cold, such as blocked nose, runny nose, sore throat, light cough or high temperature up to 38 degrees Celsius? *

Yes

No

Do you have a fever (38 degrees Celsius or more)? Fever is a measured temperature above 38 degrees Celsius, so it is not an estimate *

Yes

No

Do you recently (less than 2 weeks) suffer from vomiting and/or do you have diarrhoea? *

Yes

No

Do you recently (less than 2 weeks) suffer from shortness of breath or difficulty breathing (with light physical effort)? *

Yes

No

Do you have a member of your household/partner with COVID-19? *

Yes

No

Have you been in contact with someone with the coronavirus in the last two weeks? *

Yes

No

Truthfully filled in *

I agree that these data will be kept for 3 weeks for possible contact research by the Dutch health authorities *

I agree

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