工学部2号館電子顕微鏡室（2B12C3)入室届/Faculty of Engineering Bldg.2 SEM Room Entry Form
Version 3/2020-09-03
1.本届け出情報の利用目的：新型コロナウィルス感染防止対策のための記録。
2.提出していただいた個人情報の秘密は厳守し、感染症防止対策以外の目的では使用しません。
1. Purpose of personal information record is for activities against COVID-19.
2. Submitted personal information is protected and is only used for activities against COVID-19.
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Email *
注意： 体調不良の方、過去二週間以内に感染者（疑似含む）と濃厚接触した方、体温が平熱より高く異常だと感じる方は入室しないでください。/Note: Don't enter the clean room if you feel bad, if you meet infection or doubtful  person(s) within two weeks, and if you think abnormal that your body temperature is higher than your normal temperature.
氏名/Your name *
所属と研究責任者名/Affiliation and PI's name *
承認/Approval *
Required
健康管理報告と入構許可/Health Management and Entry permission of UTokyo https://www.u-tokyo.ac.jp/ja/general/healthcheck.html *
Required
入室予定時間/Enter time *
退室予定時間/Exit time *
17:00以降に入退出する予定の場合、夜間休日入室届が必要です。/If you enter/exit CR at after 17:00, you must send Overtime application form.  http://nanotechnet2.t.u-tokyo.ac.jp/form/otaf.php
利用予定装置/Machine(s) to use *
来校経路(手段) (例：自宅→(徒歩)→代々木上原(千代田線)→根津→(徒歩)→武田先端知ビル)/Route to Takeda (example: home->(walk)->Yoyogiuehara(Chiyoda-line)->Nezu->(walk)->Takeda bld.) *
利用日の体調、体温/Your body condition and temperature *
Required
チェックリスト/Check list *
Required
A copy of your responses will be emailed to the address you provided.
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