2020藝術志工-健康自評表【COVID-19】Health Declaration Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

因應嚴重特殊傳染性肺炎疫情，為瞭解目前居家隔離、檢疫、自主健康管理、14日內有出國旅遊史、發燒之確切人數，避免防疫缺口。請藝術家配合中央流行疫情指揮中心之政策，為降低傳染風險敬請協助問卷填答，共同維護全體健康。謝謝！
For the health and safety, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Thankyou！

Email *

填寫日期 Filing date *

YYYY

2020年期間是否有出境之旅遊史？Have you traveled abroad during 2020? *

有 Yes

無 No

若「有」出國者，請填寫旅遊之國家地區。 If "Yes", please name of the country(s) visited.

過去 14 天內是否有下列症狀：高燒、咳嗽、喉嚨痛、喘不過氣、疲勞、全身無力、嗅覺、味覺喪失等症狀（已服藥者亦須填「是」）？ Have you had the following signs and symptoms: fever, cough, runny/stuffy nose, shortness of breath, diarrhea, loss of smell or taste, malaise, limb weakness during the past 14 days? (for those who had taken medications,please answer “Yes”) *

有 Yes

無 No

您是否曾與感染，懷疑或診斷出新冠状病毒肺炎（COVID-19）的人接觸？Have you been in contact with people being infected, suspected or diagnosed with COVID-19? *

有 Yes

無 No

若「有」請寫下您與她/他們的關係以及與她/他們的最後接觸日期。If "Yes", please write down your relationship with the people and your last contact date with them.

Clear form

Never submit passwords through Google Forms.

This form was created inside of 關渡自然公園. Report Abuse

Forms