FIRST SURVEY

Please fill in all of the required fields before you send the survey. Required fields have been marked with (*)

Institute/county

PERSONAL INFORMATION

Name

Surname

Gender

Survey must contain either PIN (Personal Identification Number - Croatian OIB) or personal document information

Type of personal document

Number of personal document

Issued by

MCN

Select the address of your stay in Croatia. If the address can't be found please use the fields below this selections.

County

City/Municipality

Settlement

Street

House number and addition number

Please fill this fields if the address of your stay doesn't exist in the selections above.

City/Municipality

If not in list please select 'Ostalo - inozemstvo'

Street name and number

Phone/mobile

Closest contact phone/mobile

E-mail

Date of birth

Have you been flu vaccinated?

Have you been COVID-19 vaccinated?

Name of your general practitioner

E-mail of your general practitioner

General practitioner phone/mobile

General Practitioner's Office

SYMPTOMS

What is your current body temperature?