Survey for Departure and Arrival in Taiwan during 2020 Winter Break
Please assist us with the survey in order to provide the epidemic prevention for the outbreak of 2019-nCoV, which was first identified in Wuhan, Hubei Province, China. The new 2019-nCoV has resulted in more than a thousand confirmed cases in China, including cases outside Wuhan City. Your assistance will be greatly appreciated!
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Name: *
Employee ID: *
Gender: *
Office: *
Position: *
Year(s) at NCKU: *
Country of Residence/Citizenship: *
Have you departed from Taiwan during 2020 winter break? *
Have you ever visited to China, Hong Kong or Macao during winter break (included flight transfer at China, Hong Kong or Macao airport)? *
Country(ies) visited or layover on this trip prior to Taiwan arrival  ( Please mark N/A if you did not leave Taiwan ): *
If country(ies) you visited include Mainland China, please  specify city(ies) name, thank you ! ( Please mark N/A if you did not leave Taiwan or went to Mainland China ) *
Date of Taiwan arrival or expected date of Taiwan arrival (Please mark N/A if you did not leave Taiwan. Please indicate '' Will Not Return'' if you do not plan to return to Taiwan.) *
Health symptom(s) during 2020 winter break : *
Current state of health: *
Are you an identified case of home quarantine by the authority of Taiwan?( or Have you ever been) *
Have you ever in any physical contact with the 2019-nCoV patients ? *
Dormitory/Accommodation for 2020 spring semester: *
Please provide your email address: *
Please provide your cell phone number : *
Declaration: *
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