Name Surname Phone number E-mail Do one of more of the following questions apply to you? Check the box 'YES' if applicable:Did you have one or more of these complaints in the past 24 hours? A cough, a nose cold, a Faver from 38 degrees, shortness of breath. YesDo you currently have a roommate with a fever and/or shortness of breath? YesDid you have the coronavirus and has it been diagnosed in the past 7 days (in a laboratory)? YesDo you have a roommate/family member with the new coronavirus and have you had contact with him/her in the past 14 days while he/she still had complaints? YesAre you in quarantine because you had direct contact with someone who has been diagnosed with the new coronavirus? YesWe would like to update you about Strand Zuid Check this box if we can use your information for commercial purposes.