All fields marked with "*" are mandatory to fill
Full name - be sure to indicate in the language indicated in the identity documents (English / Ukrainian / Latin).
Home address in Ukraine
Place of work, study, children’s institution and address
Enter the full name of the place of work, study, children's institution
If you crossed the state border of Ukraine, select YES mark next to the column "Stay in countries with local transmission Covid-19", choose your country and enter return date / border crossing to transfer information in Ministry of Health of Ukraine for "Action at Home".
INFORMATION ABOUT HEALTHCARE INSTITUTION AND PHYSICIAN
Providing pre-analytical stage
Giving conclusion in English
Giving conclusion in English PCR COVID
Home visit from the nurse
¹According to the Executive Order of the Ministry of Health of Ukraine #722 from the 22nd of March 2020 in case of positive COVID-19 test result the Medical Laboratory is obliged to immediately inform the person’s Primary Healthcare Provider for the further case registration and sending the form #058/o to the laboratory center of the Ministry of Health of Ukraine.
The form #058/o/ contains personal data including place of work/study, address, age etc., thus this data is mandatory to be filled in this Questionnaire.