You'll find below your personal details form.

Please present this form and the

QRCode to the operator during admission before performing your test.

Last name: renaud

First name: Jean
Birthdate: 1980-04-24
Birthplace: MEAUX
Zipcode of birth: 77100
Country of birth: FRANCE
Gender: Man
Are you a healthcare professional ?: No
Social security number: 0
Dialling code: +33
Phone number: 0614567842
E-mail: jean.renaud@wanadoo.fr
What type of accommodation will you be staying in ?: Individual accommodation
Address: 24 r Aristide Briand
City: MEAUX
Zipcode: 77100
Country: FRANCE
Do you have any symptoms of COVID-19 ?: Asymptomatic
Have you been vaccinated against COVID-19 ?: Yes

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 This document is only saved locally on your mobile phone. Data were not transferred to eOS-COVID.
Data will only be transferred to them when you show the QRCode to the data inputter to do your test.

Data required on that form are mandatory and saved on a file by eOS-COVID for a follow-up on your
antigenic analysis.
Everything collected will only be given to the recipients that are taking part in the setting up and
realisation of the test via SI-DEP (Système d'Informations de DEPistage).
Data are stored by eOS-COVID and your identity is made anonymous permanently.
By doing the antigenic test, you are giving your full and informed consent regarding the collection and
use of your personal data.
In accordance with the 6th January 1978 "IT and Rights" law, you enjoy access, rectification,
modification and suppression rights regarding your personal data.
To exercise this right or for any other question on the processing of your data, you can contact sidep-
rgpd@sante.gouv.fr

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