Did you have one or more of the following symptoms in the past 24 hours? (obligated)
Coughing / Symptoms of a common cold / Fever or elevated temperature / Shortness of breath / Loss of taste and smell
YesNo

Does someone in your household have a fever and/or shortness of breath? (obligated)
YesNo

Have you had a novel coronavirus infection? (Laboratory-confirmed in the past 7 days)? (obligated)
YesNo

Does someone in your family or household have a COVID-19 infection and have you had contact with them in the past 14 days while they still had problems? (obligated)
YesNo

Are you in quarantine because you have had direct contact with someone with a confirmed COVID-19 infection? Or have been in a code orange or code red country (the past 14 days)? Codes can be found on www.netherlandsworldwide.nl/travel (obligated)
YesNo

Your Name (obligated)

Your Phone Number (obligated)

E-mail Address

With how many people are you?