2021-10-31 Taiwan Hostfamily Program COVID-19 Survey教育部｢友善臺灣-境外學生接待家庭專案計畫」境外學生健康關懷問卷

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Dear students,

In accordance with Taiwan CDC, due to the outbreak of Coronavirus Disease 2019 (COVID-19), please fill in the following information below.

*If you have traveled to abroad after 1 September 2021, you must conduct home quarantine or self-quarantine for 14 days. Besides, if you enter through the mini three links(Kinmen) or transfer via other nations, it is necessary to conduct a 14-day quarantine as you entered Taiwan. Going to school/work and host family visiting are both prohibited during these 14 days. We recommend to visit host families after your quarantine and 7 days of Self-health Monitoring。
參酌我國衛生福利部疾病管制署之防疫建議，因應「嚴重特殊傳染性肺炎」疫情，敬請協助填寫此份調查表。

＊若您在2021年9月1日後有出國，在入境臺灣後您必須馬上進行居家隔離或檢疫14天。此外，透過小三通(金門)入境，或是由經其它國家轉機也需自入境臺灣開始起進行14天居家管理，這14天期間，禁止上課上班也禁止拜訪接待家庭。計畫辦公室建議您於隔離後(居家隔離14天及自我健康管理7天)拜訪接待家庭。

If you join any events held by Taiwan Hostfamily Program, do NOT TAKE OFF your mask during the WHOLE event. (People who break the rules will be fined between NT$60,000 and NT$300,000.) 若參與計畫舉辦之實體活動，請勿於活動期間脫下口罩! (違反以上規定者將處新臺幣 3 千元以上 1 萬 5 千元以下罰鍰)

姓名Name(as shown on passport) *

生理性別Gender *

男性 Male

女性 Female

其他 Other

出生年月日Date of birth *

YYYY

國籍Nationality *

在臺大專校院 University in Taiwan *

聯絡電話Contact phone number *

e-mail *

現居地址/宿舍 Address/Dormitories *

您是否已施打疫苗了 Have you been vaccinated yet? *

是 Yes

否 No

如上一題答案為"是yes"，請說明您是否已施打第二劑疫苗 If you ticked yes in the previous question, please specify that have you received your second shot?

您是否曾與感染嚴重特殊傳染性肺炎（武漢肺炎）病患接觸？Have you ever in any physical contact with the COVID-19 patients ? *

是 Yes

否 No

您是否近一個月內，曾與居家檢疫/居家隔離的人接觸？(Have you contact or meet with person who is home quarantine/self-quarantine during the past month?)

是 Yes

否 No

Clear selection

您近一個月內是否有出國?Have you ever been abroad during the past month? *

是 Yes

否 No

承上題，有出國的話是去哪個國家?According to the previous question, which country do you go abroad?(If the answer is no, the question need not to be answered)

2021年9月1日後是否曾出國(含其它國家或地區轉機)? Have you been to abroad (including plane transfer/ stopover in other nations or areas) after 1 September 2021? *

是 Yes (請回答以下問題Please answer the questions below)

否 No (請略過以下問題並送出表單Skip the questions below and click to submit)

如上一題答案為"是yes"，請說明為哪個城市或機場 If you ticked yes in the previous question, please specify which city and airport.

入境臺灣日期Date of arrival in Taiwan

YYYY

預定行程(含轉機資料)Scheduled itinerary(including transfer information) e.g. Your final destination is Taiwan, if you transfer or transit in other nations or areas, please fill the detailed location below.

是否有發燒（額溫 ≧37.5℃、耳溫 ≧38℃）或急性呼吸道感染症狀 Have you had a fever (forehead temperature ≧ 37.5 ℃, ear temperature ≧ 38 ℃) or symptoms of acute respiratory infection?

是 Yes

否 No

Clear selection

管理措施_自主管理開始時間 Start Date for Self-Health Management (home quarantine)

YYYY

管理措施_自主管理結束時間 End Date for Self-Health Management (home quarantine)

YYYY

您是否有RT-PCR核酸檢驗陰性證明? Do you have certificate of a negative RT-PCR test result? *

是 Yes

否 No

如上一題答案為"是yes"，請說明您何時檢驗 If you ticked yes in the previous question, please specify when did you test RT-PCR?

備註Note

Thank you for your cooperation.

If you have any questions about signing up the events, please feel free to send an email to hostfamily@stust.edu.tw

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