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嘉義長庚-武漢肺炎旅遊接觸史調查
因武漢肺炎疫情,故進行防疫措施調查,請您回答以下問題:
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一、基本資料
(一)就讀學校 *
(二)實習類別 *
(三)就讀學制 *
(四)於本院實習期間(如:109.01.01~109.02.10) *
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(五)於本院實習單位 *
(六)學號 *
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(七)姓名 *
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(八)電話 *
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(九)14天內是否自己、家人或來往朋友曾至中、港、澳門? *
(十)旅遊史或接觸對象為何?
(十一)接觸期間為幾月幾日至幾月幾日?如:2020.01.24-1.28
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