1. In which country is the facility that you were staying when you began to feel unwell in?
2. Which type of facility/event is this?
Facility Name?
3. Are you a guest?
4. What is your age?
Age Group
5. What is your gender?
6. What is your home country?
7. To which countries have you traveled to recently? (within the past 4 weeks)
10. What symptoms did you experience?
11. Are there any additional notes about your symptoms, where you sought care, potential places/sources of exposure, or any other details about your illness that you would like to share?