學生姓名 Student’s name* *

班別 Class *

你在過去十四天內曾否到過中國內地或其他地方? Have you been to mainland China or elsewhere in the past 14 days? *

你在過去十四天內的身體有否患以下症狀?請在相應的方格內標明 Please mark the symptoms you have suffering in the corresponding boxes. *

與你同住的照顧者或家人在過去十四天內曾否到過中國內地或其他地方? Have the care givers or family members living with you been to mainland China or elsewhere in the past 14 days? *

如有，請列明她/他曾到過的省份或城市。If yes, please list the province or city where she / he has been.

時期Period：由(日/月)至由(日/月) From dd/mm to dd/mm

與你同住的照顧者或家人是否曾與患有冠狀病毒(武漢肺炎)的患者或疑似患者有密切接觸? Has the caregiver or family member living with you ever had close contact with patient or suspected patient with coronavirus (Wuhan pneumonia) *

與你同住的照顧者或家人過去十四天內的身體有否患以下症狀?請在相應的方格內標明 Did the caregiver or family member living with you have the following symptoms in the past 14 days? Please mark the corresponding box *

體溫 Temperature *

我聲明在此表格中提供的一切資料均為真確 I declare that all information provided in this form is true *

簽署Signature 請填寫英文全名please type full English name *