Question 1 of 5

Did you have one or more of these complaints in the past 24 hours?

A nose cold

A cough

a fever from 38 ℃

Shortness of breath

Question 2 of 5

Do you currently have a roommate with a fever and/or shortness of breath?

Question 3 of 5

Did you have the coronavirus and has it been diagnosed in the past 7 days (in a laboratory)?

Question 4 of 5

Do you have a roommate/family member with the new coronavirus and have you had contact with him/her in the past 10 days while he/she still had complaints?

Question 5 of 5

Do you form a joint household?


Can we have your number?

We are obliged to keep records of our guests. The GGD uses this information for source and contact research. Do you leave your details? It is not mandatory, but it is sensible.



Country code:

Mobile phone:


About your data:
You give us permission to provide your data to the GGD for source and contact research. Our employees do not have access to your data. Your data is automatically deleted after 14 days. Only our management can request your data and transfer it to the GGD.

Effenaar uses . Want to know more about this service? Mail to info@horeca-intake.nl or call 0162-238 990