COVID19 REPORTING

EJSU Covid-19 Reporting

This form is to be used to report Covid-19 incidents. EJSU supported Service Personnel, Dependents and EJSU Locally Employed Civilians (LEC’s) should report any suspected or confirmed Covid-19 cases. This Covid-19 report will be directed to the relevant NATO Support Element (NSE). Any person(s) that do not wish to use this form to report CV-19 incidents, must contact their respective NSE.

Location Currently Based

Where 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 , Marmaris

If other please specify

Reporting Persons Details

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?YesNo

Are you symptomatic?YesNoPrefer not to say

What test method did you use?PCRLFTUnknownPrefer not to say

What is your Date of Birth

What 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 say

You 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 PCR

Would you like to report another COVID19 case?NoYes

Please only report multiple people on the same form if they live in the same household. For additional reports please start the form again.

Affected Person

Affected Persons Rank/Title *

Affected Persons Full Name *

Affected Persons Date of Birth

Affected 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 COVID19

You 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 say

What test method did the patient use?PCRLFTUnknownPrefer not to say

Date of COVID test *

This can be LFT or PCR

Would you like to report another affected person in the same household as the first?NoYes

Please only report multiple people on the same form if they live in the same household. For additional reports please start the form again.

Affected Person

Affected Persons Rank/Title *

Affected Persons Full Name *

Affected Persons Date of Birth

Is the patient symptomatic?YesNoPrefer not to say

What test method did the patient use?PCRLFTUnknownPrefer not to say

Affected 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 COVID19

You 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 PCR

Would you like to report another affected person in the same household as the first?NoYes

Please only report multiple people on the same form if they live in the same household. For additional reports please start the form again.

Affected Person

Affected Persons Rank/Title *

Affected Persons Full Name *

Affected Persons Date of Birth

Is the patient symptomatic?YesNoPrefer not to say

What test method did the patient use?PCRLFTUnknownPrefer not to say

Affected 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 COVID19

You 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?NoYes

Please only report multiple people on the same form if they live in the same household. For additional reports please start the form again.

Affected Person

Affected Persons Rank/Title *

Affected Persons Full Name *

Affected Persons Date of Birth

What test method did the patient use?PCRLFTUnknownPrefer not to say

Is the patient symptomatic?YesNoPrefer not to say

Affected 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 say

You 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 PCR

COVID19 Situation Details

Where are you isolating? *SFASLAUKOther

If other please specify

Have you informed your line manager?

• Yes
• No

Have Prev Med been informed?

• Yes
• No

If the answer is no please contact them on 065-32-5336.

Do you Require Additional Support?

• Yes
• No - I have sufficient support at this time

GDPR 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=c7ccabd6b96b11ec8af51cbfbea50f1f

GDPR 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-Med

Submit