AJ Test Please enable JavaScript in your browser to complete this form.Location Currently BasedWhere are you based?OtherAlbania, TiranaAustria, ViennaBelgium, BrusselsBelgium, SHAPEBosnia and Herzegovina, SarajevoBulgaria, SofiaCroatia, ZagrebCzechia, PragueDenmark, CopenhagenDenmark, KarupEstonia, TallinnEstonia, TartuFinland, HelsinkiFrance , ParisFrance, BesanconFrance, BordeauxFrance, BrestFrance, CazauxFrance, CoetquidanFrance, DraguignanFrance, HyeresFrance, IstresFrance, LilleFrance, LyonFrance, MarseilleFrance, Mont de MarsanFrance, MourmelonFrance, NancyFrance, OrleansFrance, PoitiersFrance, RennesFrance, SaumurFrance, ToulonFrance, ToulouseGermany, BaumholderGermany, BerlinGermany, CologneGermany, DiepholzGermany, EckernfoerdeGermany, FlensburgGermany, GeilenkirchenGermany, GochGermany, HalbergmoosGermany, HamburgGermany, IngolstadtGermany, JeverGermany, LaageGermany, LeipzigGermany, ManchingGermany, MunichGermany, MunsterGermany, OberammergauGermany, OberstdorfGermany, OldenburgGermany, RamsteinGermany, RostockGermany, SonthofenGermany, StrausbergGermany, StuttgartGermany, UedemGermany, UlmGermany, VilseckGermany, WeselGermany, WiesbadenGermany, WunstorfGreece, AthensGreece, ThessalonikiHungary, SzekesfehervarItaly, NaplesItaly, PisaItaly, Poggio RenaticoItaly, RomeItaly, San RemoItaly, SigonellaItaly, Solbiate OlonaItaly, TarantoItaly, TurinKosovo, PristinaLatvia, RigaLithuania, VilniusLuxembourg, CapellenNetherlands, AmersfoortNetherlands, BrunssumNetherlands, Den HelderNetherlands, DoornNetherlands, EindhovenNetherlands, RotterdamNetherlands, TexelNetherlands, The HagueNetherlands, UtrechtNorth Macedonia, SkopjeNorway, BergenNorway, BodøNorway, ElverumNorway, OsloNorway, SorreisaNorway, StavangerPoland, BydgoszczPoland, ElblagPoland, SzczecinPoland, WarsawPortugal, LisbonRomania, BucharestRomania, SibiuSerbia, BelgradeSlovakia, BratislavaSpain, AlbaceteSpain, GetafeSpain, MadridSpain, RotaSpain, TorrejonSpain, ValenciaSweden, StockholmTurkey , AnkaraTurkey , IstanbulTurkey , IzmirTurkey , MarmarisIf other please specifyReporting Persons DetailsReporting Persons Service/Staff Number *Reporting Persons Rank/Title *Reporting Persons Full Name *Reporting Persons Contact Telephone Number *Reporting Persons Preferred Contact Email Address *Reporting Persons Place of Work if ApplicableAre you reporting yourself as an affected person?YesNoAre you symptomatic?YesNoPrefer not to sayWhat test method did you use?PCRLFTUnknownPrefer not to sayWhat is your Date of BirthWhat is your Vaccination Status?I have had my first vaccination for COVID19I have had both my first and second vaccination for COVID19I have had my first, second and Booster Vaccination for COVID19I have had no vaccinations for COVID19Prefer not to sayYou are not obliged to give this information however it would be aid us in giving you the best and most accurate advice and guidance possible.Date of COVID test *This can be LFT or PCRWould you like to report another COVID19 case?NoYesPlease only report multiple people on the same form if they live in the same household. For additional reports please start the form again.Affected PersonAffected Persons Rank/Title *Affected Persons Full Name *Affected Persons Date of BirthAffected Persons Vaccination StatusI have had my first vaccination for COVID19I have had both my first and second vaccination for COVID19I have had my first, second and Booster Vaccination for COVID19I have had no vaccinations for COVID19You are not obliged to give this information however it would be aid us in giving you the best and most accurate advice and guidance possible.Is the patient symptomatic?YesNoPrefer not to sayWhat test method did the patient use?PCRLFTUnknownPrefer not to sayDate of COVID test *This can be LFT or PCRWould you like to report another affected person in the same household as the first?NoYesPlease only report multiple people on the same form if they live in the same household. For additional reports please start the form again.Affected PersonAffected Persons Rank/Title *Affected Persons Full Name *Affected Persons Date of BirthIs the patient symptomatic?YesNoPrefer not to sayWhat test method did the patient use?PCRLFTUnknownPrefer not to sayAffected Persons Vaccination StatusI have had my first vaccination for COVID19I have had both my first and second vaccination for COVID19I have had my first, second and Booster Vaccination for COVID19I have had no vaccinations for COVID19You are not obliged to give this information however it would be aid us in giving you the best and most accurate advice and guidance possible.Date of COVID test *This can be LFT or PCRWould you like to report another affected person in the same household as the first?NoYesPlease only report multiple people on the same form if they live in the same household. For additional reports please start the form again.Affected PersonAffected Persons Rank/Title *Affected Persons Full Name *Affected Persons Date of BirthIs the patient symptomatic?YesNoPrefer not to sayWhat test method did the patient use?PCRLFTUnknownPrefer not to sayAffected Persons Vaccination StatusI have had my first vaccination for COVID19I have had both my first and second vaccination for COVID19I have had my first, second and Booster Vaccination for COVID19I have had no vaccinations for COVID19You are not obliged to give this information however it would be aid us in giving you the best and most accurate advice and guidance possible.Would you like to report another affected person in the same household as the first?NoYesPlease only report multiple people on the same form if they live in the same household. For additional reports please start the form again.Affected PersonAffected Persons Rank/Title *Affected Persons Full Name *Affected Persons Date of BirthWhat test method did the patient use?PCRLFTUnknownPrefer not to sayIs the patient symptomatic?YesNoPrefer not to sayAffected Persons Vaccination StatusI have had my first vaccination for COVID19I have had both my first and second vaccination for COVID19I have had my first, second and Booster Vaccination for COVID19I have had no vaccinations for COVID19Prefer not to sayYou are not obliged to give this information however it would be aid us in giving you the best and most accurate advice and guidance possible.Date of COVID test *This can be LFT or PCRCOVID19 Situation DetailsWhere are you isolating? *SFASLAUKOtherIf other please specifyHave you informed your line manager?YesNoHave Prev Med been informed?YesNoIf the answer is no please contact them on 065-32-5336.Do you Require Additional Support?YesNo - I have sufficient support at this timeGDPR Agreement *I consent to having the European Joint support Unit store my submitted information to enable them to perform support functions required by the Ministry of Defence. I understand that the information I provide will be shared with DPHC medical personnel and your chain of command who may contact me directly for clinical or support purposes. Further consent will be gained should my information need to be shared more widely with UK or host nation medical personnel.For more information please refer to the MOD Privacy Policy - https://www.gov.uk/government/publications/ministry-of-defence-privacy-notice/mod-privacy-notice?msclkid=c7ccabd6b96b11ec8af51cbfbea50f1fGDPR Agreement - Prev Med - SHAPE *I consent to having the European Joint support unit share my information with host nation medical personnel.This is required at SHAPE only to inform Prev-MedSubmit
