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實踐大學高雄校區居家隔離通報
各位師長暨同學 大家好:
此份通報表單僅提供密切接觸者(如同住親友、室友、共桌吃飯者有人確診)通報,
非上述情形者請勿填報 ,感謝配合!
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Email
*
Your email
班級/單位(範例:國貿一甲,進服一甲,生輔二組)*
*
Your answer
學號/員工編號
*
Your answer
姓名
*
Your answer
性別
*
男
女
年齡
*
Your answer
聯絡電話(範例:0911-007-800)
*
Your answer
出生年月日
*
MM
/
DD
/
YYYY
接觸者身分(關係)
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Your answer
接觸日期
*
MM
/
DD
/
YYYY
是否就醫
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是
否
Other:
接觸時是否配戴適當個人防護裝備
*
是
否
Other:
接觸地點
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Your answer
居住縣市
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Your answer
居住鄉鎮市區
*
Your answer
居住地址
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Your answer
國籍
*
Your answer
是否有符合1人1室的隔離房間
*
有，且獨立衛浴
有，但須共用衛浴
Other:
LINE 暱稱
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Your answer
LINE ID
*
Your answer
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