Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
傳染病通報單
師生通報傳染病時,煩請老師家長協助完成表單填寫, 生病之師生應在家休息,落實生病不上課不上班,以維護全校師生健康。
學務處衛生組感謝您!!
* Indicates required question
Email
*
Record my email address with my response
年班級 座號 (教職員工請填寫 處室+職稱)
*
Your answer
姓名
*
Your answer
電話
*
Your answer
疾病症狀 (發燒 咳嗽 肌肉痠痛、 口腔潰瘍 手腳起水皰....)
*
Your answer
通報疾病
*
A型流感
B型流感
腸病毒
水痘
腹瀉
急性出血性結膜炎
疥瘡
頭蝨
其他 (請接續下題說明)
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms