2021 TIS桃園市第一屆鐵人兩項錦標賽-健康告知書
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全名 與護照相同 (大寫) Full Name as it appears in passport / travel document (IN BLOCK LETTERS)
國籍 Nationality
身分證 (護照)號碼 ID No. / Passport No. / IRC No.
地址 / 外籍人士在台聯絡地址 Address / Contact details in Taiwan for Foreigners:
郵遞區號 Postal Code
聯絡電話 Contact No:
您是否有以下症狀? Do you have any of the following symptoms?• 發燒 (超過37.5度) Fever (>37.5⁰C)• 腹瀉與嘔吐 Diarrhea and Vomiting• 喉嚨痛或乾咳 Sore throat or cough• 肌肉酸痛,頭痛,發冷及頭暈 Body Aches, Headaches, chills and fatigue• 流鼻水 Runny Nose• 呼吸急促 Shortness of breath
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您或您的家人是否曾接近近嚴重特殊傳染性肺炎(COVID-19, 新冠肺炎患者)/被居家隔離者/居家檢疫/自主健康管理中,或共同生活/共事者需檢疫/隔離/確診?Have you or your family members/colleague had contact* with any COVID-19 affected persons, persons under Home Quarantine Order or persons who may have visited any high risk COVID-19 locations?*
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"接近"意指曾照顧過,與其同住或直接接觸其呼吸道液體或體液者Contact means having cared for, having lived with, or having direct contact with respiratory secretions or body fluids.
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過去十四天內是否從其他國家返(抵)台?Have you travelled to any country in the past 14 days?
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接種疫苗是否滿14天Was vaccination within 14 days
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本人已詳細閱讀並聲明上述內容均屬實無誤,且同意簽署此聲明書; 亦瞭解隱瞞事實或提供不實資料乃違反防疫法之行為。為降低任何傳染風險與維護全體民眾及選手的健康, 本公司將保留相關法律追訴權及損害求償之權益。I have read and declared that the above content is true and correct, and I agree to sign this declaration; I also understand that concealing facts or providing false information is a violation of the Anti-epidemic Law. In order to reduce any risk of infection and maintain the health of all the people and players, the company will retain the right of legal prosecution and damage claims.
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