2022-10-22/2022-10-23 Overseas students COVID-19 Survey境外學生健康關懷問卷

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear students,

In accordance with Taiwan CDC’s suggestion and in order to protect the health of all participants, all participants who join in this program must cooperate to fill in the “Health Care Survey”. Your personal data collected by us via this survey contains your personal identification information (i.e., your name), medical records, healthcare data, contact information, data concerning your social activities, and other data that is necessary for us to take antiepidemic measures. Your personal data will not be used for any purpose other than the aforementioned epidemic prevention purposes.

*If you have any COVID-19 related symptoms, especially those who returned from abroad recently, please go to the nearest hospital for the examination, or any medical assistance.

Email *

姓名Name(as shown on passport) *

生理性別Physical 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, 已打第一劑 Yes, I've got the first dose.

是, 已打第二劑 Yes, I've got the second dose.

是, 已打第三劑 Yes, I've got the third dose.

是, 已打第四劑 Yes, I've got the furth dose.

否 No

您是否有PCR核酸檢驗陰性證明? Do you have a PCR "Negative" certificate?
*

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 take the PCR test?

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

您近一個月內是否有離開臺灣? Have you ever been out of Taiwan during the past month?
*

是 Yes

否 No

承上題，有出國的話是去哪個國家?Following the previous question, what country have you been to during the past month?

If the answer is no, you can skip the question.

入境臺灣日期Date of arrival in Taiwan

YYYY

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

檢疫隔離開始時間 Start date for quarantine

YYYY

檢疫隔離結束時間 End Date for quarantine

YYYY

備註Note

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

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of 南臺科技大學. Report Abuse

Forms