國立高雄科技大學新冠肺炎主動回報聯絡單   NKUST Health Care Survey for COVID-19
您好：
Dear Students, Faculty, and Staff,
一、因應目前國內本土疫情嚴峻，持續有本土確診個案，若您收到衛生局通知您確診或與確診者為密切接觸者，必須進行「確診住院隔離」、「確診者居家照護」或「密切接觸者居家隔離+自主防疫」時，請主動回報本校並填寫表單，以利本校能第一時間關心您的健康狀況。
In response to the recent local Covid-19 cases, if you have been notified by CDC or  Health Bureau that you're a confirmed case or closed contact with COVID-19 case, please fill in the survey so that school could  reach you as soon as possible.
二、通報聯絡電話：
       (一)學務處衛保組07-3814526#12531-12534(建工)、18535(燕巢)、22086-22089(楠梓)、25085(旗津)、
             31251-31255(第一)(服務時間：週一至週五08:00-17:00)
       (二)校安中心專線：0800-550-995
       學務處關心您
If you have any questions, concerns, or just need some assistance while isolating at homeor in a hospital,  please contact OIA directly.
       Tell: 07-3814526 #19032
       Email: qaoffice01@nkust.edu.tw
       *必填  "*" mean required questions.  
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一、校區Campus *
二、身份別Identity *
三、系所/單位Department/School/Office *
四、職編/學號Student/Employee ID No. *
五、姓名 Name *
六、聯絡手機Mobile Number *
七、E-mail *
八、您何時接到衛生單位通知/？When did you receive the notification from a health bureau/CDC?
MM
/
DD
/
YYYY
九、您目前被衛生局通知為追蹤管理對象為哪一種？What is your condition now? *
十、您目前住院隔離、居家照護或居家隔離地點？(請說明住院醫院名稱、居家隔離旅館名稱或自宅地址)Please leave your current residential address during  isolation. If you're in hospital or quarantine hotel/center, please leave  the name and address of the hospital, hotel or center.                           *
十一、請問您接種過幾劑新冠疫苗 How many COVID-19 vaccines have you been vaccinated? *
十二、請問您接種的疫苗品牌以及最後一劑接種的日期? Please submit the Vaccine Brands and the last vaccination date. (如:  AZ/BNT/Moderna  , 2022/01/10) *
十三、目前您的症狀有哪些?Please describe your symptoms. *
十四、其他(狀況描述或需協助事項)Any assistance you need from us (please describe in detail). *
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