Where are you based? Other Albania, Tirana Austria, Vienna Belgium, Brussels Belgium, SHAPE Bosnia and Herzegovina, Sarajevo Bulgaria, Sofia Croatia, Zagreb Czechia, Prague Denmark, Copenhagen Denmark, Karup Estonia, Tallinn Estonia, Tartu Finland, Helsinki France , Paris France, Besancon France, Bordeaux France, Brest France, Cazaux France, Coetquidan France, Draguignan France, Hyeres France, Istres France, Lille France, Lyon France, Marseille France, Mont de Marsan France, Mourmelon France, Nancy France, Orleans France, Poitiers France, Rennes France, Saumur France, Toulon France, Toulouse Germany, Baumholder Germany, Berlin Germany, Cologne Germany, Diepholz Germany, Eckernfoerde Germany, Flensburg Germany, Geilenkirchen Germany, Goch Germany, Halbergmoos Germany, Hamburg Germany, Ingolstadt Germany, Jever Germany, Laage Germany, Leipzig Germany, Manching Germany, Munich Germany, Munster Germany, Oberammergau Germany, Oberstdorf Germany, Oldenburg Germany, Ramstein Germany, Rostock Germany, Sonthofen Germany, Strausberg Germany, Stuttgart Germany, Uedem Germany, Ulm Germany, Vilseck Germany, Wesel Germany, Wiesbaden Germany, Wunstorf Greece, Athens Greece, Thessaloniki Hungary, Szekesfehervar Italy, Naples Italy, Pisa Italy, Poggio Renatico Italy, Rome Italy, San Remo Italy, Sigonella Italy, Solbiate Olona Italy, Taranto Italy, Turin Kosovo, Pristina Latvia, Riga Lithuania, Vilnius Luxembourg, Capellen Netherlands, Amersfoort Netherlands, Brunssum Netherlands, Den Helder Netherlands, Doorn Netherlands, Eindhoven Netherlands, Rotterdam Netherlands, Texel Netherlands, The Hague Netherlands, Utrecht North Macedonia, Skopje Norway, Bergen Norway, Bodø Norway, Elverum Norway, Oslo Norway, Sorreisa Norway, Stavanger Poland, Bydgoszcz Poland, Elblag Poland, Szczecin Poland, Warsaw Portugal, Lisbon Romania, Bucharest Romania, Sibiu Serbia, Belgrade Slovakia, Bratislava Spain, Albacete Spain, Getafe Spain, Madrid Spain, Rota Spain, Torrejon Spain, Valencia Sweden, Stockholm Turkey , Ankara Turkey , Istanbul Turkey , Izmir Turkey , Marmaris
If other please specify
Reporting 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 Applicable
Are you reporting yourself as an affected person? Yes No
Are you symptomatic? Yes No Prefer not to say
What test method did you use? PCR LFT Unknown Prefer not to say
Affected Persons Rank/Title *
Affected Persons Full Name *
Is the patient symptomatic? Yes No Prefer not to say
What test method did the patient use? PCR LFT Unknown Prefer not to say
Affected Persons Rank/Title *
Affected Persons Full Name *
Is the patient symptomatic? Yes No Prefer not to say
What test method did the patient use? PCR LFT Unknown Prefer not to say
Affected Persons Rank/Title *
Affected Persons Full Name *
Is the patient symptomatic? Yes No Prefer not to say
What test method did the patient use? PCR LFT Unknown Prefer not to say
Affected Persons Rank/Title *
Affected Persons Full Name *
What test method did the patient use? PCR LFT Unknown Prefer not to say
Is the patient symptomatic? Yes No Prefer not to say
Where are you isolating? * SFA SLA UK Other
If other please specify