防範嚴重特殊傳染性肺炎健康聲明書
為因應嚴重特殊傳染性肺炎(武漢肺炎),進入本場所請填寫您近期旅遊史,有助於防疫措施與防護。
請協助回答下列問題。感謝您!
姓 名 Name *
性 別 Gender *
身分證/護照號碼ID card No. / Passport No. *
聯絡電話 Telephone *
過去 14 天內是否有發燒、咳嗽或呼吸急促症狀(已服藥者亦需填寫「是」)? Have you had fever, cough, or shortness of breath during the past14 days? (for those who had taken medications, please answer “Yes”) *
請注意下列事項,以上資料僅供話畫大稻埕創意店作為疫情管制之用。
★入境 14 天內若有出入公眾場所,請務必佩戴口罩!
★依傳染病防治法第 58 條規定,入境旅客應誠實填寫及繳交至疾管署檢疫站或入境證照查驗櫃檯,並配合必要檢疫措施;如有拒絕、規避妨礙或填寫不實者,依法處新臺幣 1-15 萬元罰鍰。
★Be sure to wear a mask in public places during following 14 days.
★ According to Article 58 of the Communicable Disease Control Act, inbound passengers are required to accurately fill out and submit this card
to Taiwan CDC quarantine stations or immigration counters upon arrival, and follow quarantine regulations. Any person who refuses, evades or obstructs abovementioned measures shall be fined NT$10,000 up to NT$150,000.
中央流行疫情指揮中心衛生福利部疾病管制署(2020.03.14 十 版)
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