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Data entry form for contact persons of a person with COVID-19 infection

Have you had contact with a confirmed case of COVID-19 and would like to contact the Pankow Health Authority?
Then use the following form to contact the Pankow Health Office. By providing your complete data you will make the work of the health office staff easier. This way you support the quick follow-up of contact persons and help the Health office staff to react quickly and purposefully to possible new cases. Please note that an initial contact by individual mail to corona@ba-pankow.berlin.de cannot be processed.

By sending the form below, you are stating that you are a possible contact person at the Pankow Health Office. The Pankow Health Office is responsible for citizens with a registration address in Pankow (zur Seite des RKI) or with a predominant stay in Pankow. Please describe your contact to the positive tested person as precisely and in detail as possible and provide all the necessary information requested. This saves the staff a lot of work and enables the public health department to process the inquiries effectively.
The final classification into a contact person category will be made by employees of the health office. A quarantine can only be declared after the Health Department has classified you as a Category I contact person.

Category I contact person according to the contact categories of the RKI recommendations:
Cumulative at least 15 min. face-to-face contact, e.g. persons in direct conversation, direct body contact with secretions or body fluids or contact person was exposed to a high aerosol concentration regardless of the distance, e.g. celebrating, singing together or doing sports indoors without adequate ventilation.
Contact person category II according to contact categories of the RKI recommendations:
Less than 15 min. face-to-face contact, e.g. persons staying in the same room, no direct physical contact.

We thank you for your cooperation and wish you all the best!
Your health office Pankow

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Your personal data

Please choose an option.
Please choose an option.
Please choose an option.

Example: (030) 123 456 89

Example: vorname.nachname@berlin.de

With your consent to the use of your e-mail address, you agree that the Pankow Health Department can contact you via this address and, if necessary, orders and findings may be sent to you. Please also check your SPAM folder for messages from the health department.

The advantage of transmitting via email is that the findings and orders can be sent at short notice. We would like to point out, however, that sending by e-mail can only be an unencrypted – and therefore unsecured – transmission. If you decide not to send it by email, delivery will be made by post with the usual delivery times.

Please choose an option.

Information about your with COVID-19 infected person

Example: 01.05.2016

Please choose an option.

Example: (030) 123 456 89

Example: 01.05.2016

In case you don’t have all the necessary information, please contact the infected person or the institution that informed you about the fact that you are a contact person to ask for the required data.

Example: 01.05.2016

Example: 01.05.2016

Further information about you

Example: 01.05.2016

Information über die Gesetzliche Grundlage

Internetseite des Datenschutzbeauftragten

Contacting the Data Protection Officer

Boris Hube

Bezirksamt Pankow von Berlin
Datenschutzbeauftragter
Breite Straße 24A-26
13187 Berlin

E-mail: Contact

Datenschutzerklärung