Česká verze

Quarantine or COVID 19 infection report

Take a few minutes to complete this questionaire:

1 You want to report the quarantine due to:

Help: choose one answer

2 In case of your stay abroad please indicate the place (country, location):

3 Do you want to report your own infection or suspection on COVID

Question Help: Select one answer for each question

4 Your e-mail address:

5 Enter your personal data (mobile phone number, address of the place of your stay):

6 In case if a COVID 19 infection is proven by you or if you are at home-quarantine because you have been in contact with a risk person/s and you have clinical symptoms at the same time, who were you in contact with from the Faculty of Medicine in Pilsen and Faculty Hospital in Pilsen during last 14 days?

7 Employee of Faculty of Medicine in Pilsen:

8 Your name and surname, study program, year of study (by employees their workplace). Date of start of the quarantine or hospitalization. Date of the report.
9 Antispam control: two + three =