Covid-19 (suspected) Infection Report Form

Mandatory fields are marked with an asterisk (*).

Name *

First name *

Date of birth *

Statusgroup *

Student number / Employed at *

Students: Please enter your matriculation / student number.

Employees: Please enter your place of employment.

Address *

Place of residence / District *

E-Mail *

Category *

Information regarding contact history and exposure to COVID-19 by Robert-Koch-Institut (german)

Suspected infection / Tested positive on (date) *

For Employees: Has your supervisor been informed?

Yes

Have contacts (category I) been informed?

Yes

For students: Which lectures / classes have you attended in person?

Further information

Statement *

Ich erkläre mich einverstanden, dass meine hier angegebenen Daten ausschließlich zur internen Organisation der Anmeldungen elektronisch verarbeitet und gespeichert werden. Ich kann jederzeit und ohne Angabe von Gründen die Löschung meiner Daten verlangen.

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Department of History and Cultural Studies

Department of History and Cultural Studies

Covid-19 (suspected) Infection Report Form