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AVIS DE COURSE 

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Sample Personal Location Form (PLF)
To be completed by all participants of the event
Name as shown in the passport or other ID:


Your permanent address (street/apartment/City/postal number/Country):


Your address during the event:


Your telephone number:


Your e-mail address:


Countries that you visited or stayed in last 14 days
Within the past 14 days, have you:


had close contact with anyone diagnosed as having Coronavirus disease COVID-19?     YES NO
provided direct care for COVID-19 patients?
visited or stayed in a closed environment with any patient having Coronavirus disease COVID-19?  YES NO
worked together in close proximity, or sharing the same classroom environment with COVID-19 Patient? YES NO 
traveled together with COVID-19 patient in any kind of conveyance?  YES NO
lived in the same household as a COVID-19 patient?       YES NO 

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