The following must, at a minimum, be inventoried per :
Full name:
First name:
Birth date:
Have you suffered or do you still suffer from:
Typhoid: Yes / No
Paratyphoid: Yes / No
Tuberculosis: Yes / No
Contagious skin diseases: Yes / No
If so, which:
Any other infectious diseases: Yes / No
If so, which:

Have you contracted a strange abroad:
For a contagious disease not listed above: Yes / No
If yes, which:

If someone has suffered from the following diseases or conditions within 24 hours before the start of their shift, the must be notified:
Stomach pain with fever
Visibly infected areas of skin (burns, cut wounds, etc.)
Runny ear, eye, or nose

The undersigned declares that the above information has been filled in truthfully:

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