姓 名 Name
性 別 Gender
女 性 Female
身分證/護照號碼ID card No. / Passport No.
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”)
★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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