UOW College Hong Kong/Community College of City University : Health Declaration Form 健康申報表
Name 姓名 *
Your answer
Student / Staff ID 學生或職員編號 *
Your answer
Department/Faculty 所屬部門 / 學院 *
Contact Number 聯絡電話 *
Your answer
Have you travelled outside Hong Kong in the last 14 days? 你在過去14日內是否曾離開香港? *
If Yes, please list the countries and cities that you visited in the past 14 days (if not applicable, please insert "N/A") 如你曾離開香港,請列出在過去十四日內你到過的國家和城巿 (如有不適用者, 請填「不適用」) *
Your answer
Have you visited hospitals or close contact with patient with significant infective disease? 你在過去14日內有否到訪醫院或與傳染病者有緊密接觸? *
If Yes, please specify the details (if not applicable, please insert "N/A") 如有, 請提供詳細資料 (如有不適用者, 請填「不適用」) *
Your answer
Do you have any of the following symptom(s)? 你是否有以下的病徵?(Please tick as appropriate) *
Yes 是
No 否
Fever 發熱
Chills & Rigor 發冷
Cough咳嗽
Diarrhoea 肚瀉
Shortness of breath氣喘
If Yes, specify number of days of the symptoms (if not applicable, please insert "N/A") 如有, 列出各徵狀的持續日數 (如有不適用者, 請填「不適用」) *
Your answer
Declaration 聲明書 *
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