健康申報表 Self-declaration Form

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為防止2019 冠狀病毒在我們的社區中蔓延，並保障The Wave會員、訪客及員工的健康及安全，所有訪客須於進入The Wave前填寫一份簡單的健康申報表，感謝您的合作！
To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our members, visitors and staff, all visitors are required to submit the declaration form once entering The Wave. Thank you for your cooperation!

姓名 Name (須與身份證相同 Must be the same as shown on your HKID card/Passport) *

電話號碼 Contact No. *

電郵 E-mail (選填 Optional)

到訪日期 Date of Visit *

YYYY

到訪樓層 Floor of Visit *

7/F

8/F

9/F

10/F

11/F

本人居住的大廈於過去14日內曾經有確診個案 My residential building is under the list in which confirmed / probable cases have resided *

有 Yes

沒有 No

本人工作的地方/大廈於過去14日內曾經有確診個案 My workplace is under the list in which confirmed / probable cases have resided *

有 Yes

沒有 No

本人申報、聲明及同意如下: I hereby declare and agree that: *

本人現時及過去 14 日內並無以下任何症狀，包括發燒、乏力、咳嗽、氣促、呼吸困難、咽喉痛或感冒症狀。I do not have and have not had in the past 14 days any of the following symptoms – fever, malaise, cough, shortness of breath, sore throat or other flu-like symptoms.

本人在過去 14 日內並無去過中國內地 I have not been to the Mainland in the last 14 days.

本人在過去 21 日內並無去過其他國家或地區 I have not been to the any overseas countries and regions in the last 21 days.

本人並未曾與在過去 14 日曾離開香港的任何人士有密切接觸^^，尤其是家人、家庭傭工及司機 I have not been in close contact^^ with any person who has travelled outside Hong Kong in the past 14 days, in particular family members, domestic helpers or drivers.

本人在過去 14 日內並未曾與任何確診人士或懷疑確診人士（無論在香港或海外）有密切接觸^^ I have not been in close contact^^ with any person who is a confirmed or preliminary positive case of COVID-19 infection in Hong Kong or overseas in the past 14 days.

本人無須按強制檢測公告或指示接受 2019 冠狀病毒病檢測/本人曾經按強制檢測公告或指示接受 2019 冠狀病毒病檢測而檢測結果為陰性。I am not required to undergo COVID-19 testing pursuant to a compulsory testing notice or direction / I have undergone COVID-19 testing pursuant to a compulsory testing notice or direction and the result is negative.

本人聲明據本人所知及所信，以上資料均屬正確無誤 I hereby declare that the above information is true and accurate to the best of my knowledge.

Required

^^「密切接觸」是指直接接觸、居於同一家庭、乘坐同一車輛或飛機、或有近距離社交接觸，例如一同進餐。　以上僅列舉部分例子以作參考。如有懷疑，The Wave建議閣下應採取謹慎做法，即避免使用本會設施。

^^ “Close contact” generally means having direct physical contact, living in the same household, travelling in the same vehicle or flight, having social contact in close proximity such as dining together. The above examples are not exhaustive. If you are in doubt, The Wave advises that you should on the side of caution and refrain from using our facilities.

所收集的資料僅為確保The Wave環境安全及健康，如果需要，收集的資料將會用於聯繫追踪。The personal data provided will be used for ensuring the environmental safety and health of The Wave. Information collected is used for contact tracing if required.

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