JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Epidemiology QUESTIONNAIRE
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name and surname:
*
Your answer
Passport number:
*
Your answer
Address and contact phone in Serbia:
*
Your answer
Faculty you study in Serbia:
*
Your answer
Date of entry into the Republic of Serbia:
*
MM
/
DD
/
YYYY
1.
Have you had or have been diagnosed with COVID 19 infection
*
Yes
No
If YES - when?
Your answer
2.
Have you had any of the following symptoms in the last 10 days:
elevated temperature
loss of sense of taste
loss of sense of smell
sore throat
runny nose
cough
stomach (intestinal) problems
weakness
3.
Is someone from your household was diagnosed with COVID 19 infection
*
Yes
No
if YES - specify when:
Your answer
4.
Is someone from your household in the last 2 weeks had some of the symptoms listed in question no.2
*
Yes
No
if YES - specify any of the symptoms:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
