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Covid 19 - Questionnaire English
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 *
Number of persons belonging to this household *
1
2
3
4
5
6
7
8
9
10
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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