COVID-19 checklist

Download the flyer to use in your company

Dear guest,


Welcome to our organization.

We are obliged to ask you a number of questions regarding your health before visiting our company. We do this via the online checkup / health check. The answers you choose are not saved and cannot be traced back to you personally.

Answer all the questions found in the form. When you press send, a green check or a red message appears. In case you receive a green check, you may show that to one of our employees and you are very welcome to enter our facility. If you receive a red notification, we politely ask you to consult with one of our employees.

Please answer the following questions


1. Did you have problems with coughing during the past 2 hours?
2. Have you had a cold during the past 24 hours?
3. Have you had a fever (more than 38° C) during the past 24 hours?
4. Did you experience shortness of breath in the past 24 hours?
5. Do you currently have a roommate with a fever and / or shortness of breath?
6. Have you had the coronavirus and has it been diagnosed in the past 7 days?
7. Do you have a roommate / family member with coronavirus and did you have contact with him / her during the past 14 days while he / she still had complaints?
8. Are you in home isolation because you have had direct contact with someone diagnosed with the coronavirus?
Please enter your first name.