Questionnaire to Prevent the Spread of Communicable

Diseases

Name: Stanislav Ivanov Mihalev

Date: 08.10.2021 Location:
Bulgaria
E-Mail: Mihalev.Stanislav@deme-group.com
+359 883 365 322
Phone:

Company:
DEME Offshore

In order to assist us in preventing the spread of communicable diseases, we would like you to answer the
following questions:

1. Have you stayed in a risk country designated by the RKI (Robert-Koch-

Institut) in the last 14 days?
x No
 Yes / 

If yes, have you been tested negative for corona x No

 Yes / 

2. Have you within the last 14 days had close contact with, or helped care for,
anyone suspected or diagnosed as having Coronavirus, or who is currently x
 Yes /  No

subject to health monitoring for possible exposure to Coronanvirus.

3. In the past 3 days, have you had fever (38°C / 100.4°F or higher) in
connection with chills or respiratory illness symptoms such as a cough, sore
x
 Yes /  No

throat or difficulty breathing?

4. Within the last 3 days, have you developed symptoms of diarrhea or
vomiting?
x No
 Yes / 

This questionnaire may be reported to the relevant authorities. Of course we will adhere to the General
Data Protection Regulation (GDPR) and refer to the attached data protection information for customers,
suppliers and partners.
I certify that the above declaration is true and correct and that any dishonest answers may have
serious public health implications.

08.10.2021
Date, Signature: _________________
Stanislav Mihalev