高雄醫學大學本人與同住者110/4/15-4/29旅遊及活動史調查 Travel and activity history survey of KMU employees and their household members from April 15 to 29, 2021
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姓名Name *
職號Employee No. (臨時工請填000, 000 for temporary worker) *
身份Identity *
單位 (計畫人員請選計畫主持人所屬單位)Division/College (project personnel please specify your PI's) *
案1120 公共場所活動史(2021.04.30公布)
Case 1120's History of Activities in Public Places (announced on April 30, 2021)
「您」是否曾於 案1120公共場所活動史(如上圖)的時間及地點 活動?Have you ever participated in any of the activities at the time and locations mentioned in the table above? *
您的「同住者」是否曾於 案1120公共場所活動史(如上圖)的時間及地點 活動? Have your household members ever participated in any of the activities at the time and locations mentioned in the table above? *
案1127 公共場所活動史(2021.05.01公布) Case 1127's History of Activities in Public Places (announced on May 1, 2021)
「您」是否曾於案1127公共場所活動史(如上圖)的時間及地點活動? Have you ever participated in any of the activities at the time and locations mentioned in the table above? *
您的「同住者」是否曾於案1127公共場所活動史(如上圖)的時間及地點活動? Have your household members ever participated in any of the activities at the time and locations mentioned in the table above? *
案1128 公共場所活動史(2021.05.01公布) Case 1128's History of Activities in Public Places (announced on May 1, 2021)
「您」是否曾於案1128公共場所活動史(如上圖)的時間及地點活動? Have you ever participated in any of the activities at the time and locations mentioned in the table above? *
您的「同住者」是否曾於案1128公共場所活動史(如上圖)的時間及地點活動? Have your household members ever participated in any of the activities at the time and locations mentioned in the table above? *
案1129 公共場所活動史(2021.05.01公布) Case 1129's History of Activities in Public Places (announced on May 1, 2021)
「您」是否曾於案1129公共場所活動史(如上圖)的時間及地點活動? Have you ever participated in any of the activities at the time and locations mentioned in the table above? *
您的「同住者」是否曾於案1129公共場所活動史(如上圖)的時間及地點活動? Have your household members ever participated in any of the activities at the time and locations mentioned in the table above? *
案1134 公共場所活動史(2021.05.02公布) Case 1134's History of Activities in Public Places (announced on May 2, 2021)
「您」是否曾於案1134公共場所活動史(如上圖)的時間及地點活動? Have you ever participated in any of the activities at the time and locations mentioned in the table above? *
您的「同住者」是否曾於案1134公共場所活動史(如上圖)的時間及地點活動? Have your household members ever participated in any of the activities at the time and locations mentioned in the table above? *
案1136 公共場所活動史(2021.05.03公布) Case 1136's History of Activities in Public Places (announced on May 3, 2021)
「您」是否曾於 案1136公共場所活動史(如上圖)的時間及地點活動? Have you ever participated in any of the activities at the time and locations mentioned in the table above? *
您的「同住者」是否曾於案1136公共場所活動史(如上圖)的時間及地點活動? Have your household members ever participated in any of the activities at the time and locations mentioned in the table above? *
如「您」有上述旅遊/接觸史，請詳填與案"****"重疊之活動史日期、時間及地點。 If you have the above travel/contact history, please specify the date, time and place of the event that overlaps with Case “No”'s.
填寫範例: 案1120之活動史4/20、8:15~9:20及機場旅館站 Example: Case 1120’s activity history of April 20, 8:15~9:20 and airport hotel station
如您的「同住者」有上述旅遊/接觸史，請詳填與案"****"重疊之活動史日期、時間及地點 If your household members have the above travel/contact history, please specify the date, time and location of the event that overlaps with Case “No”'s.
填寫範例: 案1120之活動史4/20、8:15~9:20及機場旅館站 Example: Case 1120’s activity history of April 20, 8:15~9:20 and airport hotel station
「您」若「有上述接觸史」後，是否出現以下症狀？(可複選）With the above-mentioned contact history, do you have any of the following symptoms? (Multiple answers are accepted.) *
Required
您的「同住者」若「有上述接觸史」後，是否出現以下症狀？(可複選）With the above-mentioned contact history, does your household member have any of the following symptoms? (Multiple answers are accepted.) *
Required
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