文藻外語大學108學年教職員工健檢防疫調查表(含健康旅遊史)Survey for COVID-19 (for faculty and staff physical examination)
因應防疫需求,於活動開始前2周需調查參與人員出國史及健康資訊,請填寫以下表單,謝謝!
校內健檢日期為109年5月6日星期三上午7:30-11:00
地點: 文園1樓川堂
若您當天無法參與,請於5/16(六)前至聖功醫院3樓健檢中心完成健檢,預約電話07-2255263(醫院健檢時間為周一~六 上午8:30~11:30)。
To prevent COVID-19, please fill in this form for risk assessment, thank you.
The physical examination date : 5/6 (Wed) 7:30-11:00
Location: 1F of Wenyuan
If you can not attend the physical on 5/6, please have the examination before 5/16(Sat) at the Health Examination Center St.Joseph Hospital. Reservation:07-2255263 (Office Hours : 8:30-11:30 Mon.-Sat.)
姓名Name *
職編Staff ID *
最近一個月是否出現下述症狀? Has the following symptoms occurred within 30 days? *
Required
如有上述症狀,其起始日為?(若無不用填答) When did the above symptom appear?( Skip if choose "none")
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DD
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YYYY
過去一個月或未來一個月是否出國(含轉機)? Did you go abroad(including transfers) in the past or the next month? *
如上題為 "是",旅遊/接觸史(含轉機)地點:(若為 "否" 則不須填答) Location of above question ( Skip if choose "none")
您身體是否有這些症狀? Do you have the following health issues? *
Required
若上題為”是” 請註明疾病名稱。 What’s the diagnosis of above question?
您或與您同住的家屬或親友是否曾與感染嚴重特傳染性肺炎(武漢肺炎)病患有接觸?Have you or your family or friends who lived with you ever contact with patient of COVID-19? *
上題若為 "是",接觸者與您的關係為:(若為 "否" 則不須填答)What's the relationship between you and the contact? (Skip if choose None.)
上上題若為 "是",接觸日期為:(若為 "否" 則不須填答)?Date of contact? (Skip if choose None.)
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/
DD
/
YYYY
5/6(三)上午,您是否會參與校內健檢?Will you attend the examination on 5/6 (Wed)? *
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