國立高雄科技大學新冠肺炎回報聯絡單   NKUST  Report form for COVID-19
您好：
Dear Students, Faculty, and Staff,
一、因應國內本土疫情變化，若您快篩陽性，須「自主健康管理」時，請主動填寫本表單，以利本校掌握疫情現況。
If your COVID-19 test is postive,  please fill in the survey so that school could report to MOE(Ministry of Education).
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,   please contact OIA directly.
       Tell: 07-3814526 #19032
       Email: qaoffice01@nkust.edu.tw
三、人事室宣導：如確診期間為本校兼任計畫人員，因進行居家照護、隔離不能工作4日以上且期間未取得原有薪資或報酬者，得依規定請領普通傷病給付，相關請領事宜請洽人事室協助辧理。(分機12126、12123、12124)
       *必填  "*" required questions.  
Sign in to Google to save your progress. Learn more
1.校區Campus *
2.身份別Identity *
3.系所班級/單位Department/Office
(學生請註明班級，如:進修半導體二甲、觀光一乙)
 *
4.職編/學號Student/Employee ID No. *
5.姓名 Name *
6.性別 (校安通報需要) Gender (For report to MOE) *
7. 民國出生年(校安通報所需)Birth Year (For report to MOE) *
8.聯絡手機Mobile Number  *
9.電子信箱 mail *
10.請問您目前的狀況是？What is your status now? *
11.您目前自主健康管理或自主防疫地址？Please leave your current address during self-health management/ self-initailed prevention. *
12.若您為學校宿舍住宿生，請填寫住宿樓名及寢室號碼(如 南海樓101-1) Please leave your room number if you live at school dorms.
13. 請問您哪一天快篩陽性?   
What date did you test postive?
MM
/
DD
/
YYYY
14. 若您有看診，請問幫您看診的醫療院所名稱(如: 安心診所) Which medical institution diagnosed for you? 
15.請問您的症狀有哪些?Please describe your symptoms. *
16.其他(狀況描述或需協助事項)Any assistance you need from us (please describe in detail).
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of 國立高雄科技大學.

Does this form look suspicious? Report

Google Forms