1022-1023-HEALTH CARE SURVEY 健康關懷問卷
In accordance with Taiwan CDC’s policy 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.

您好，參酌我國疾病管制署之防疫政策，並基於保護計畫參與人員的身體生命安全，所有參與人員均須配合填寫健康，敬請協助填寫此份調查表。本單位透過健康聲明書所蒐集、處理及利用之個人資料類別包含您的識別類個人資料（姓名）、病例、醫療、聯絡方式、社會活動及其他為防疫所需之個人資料，除上述之防疫目的（下稱「蒐集目的」）外不另作其他用途。

＊若您有任何相關症狀，特別是剛入境臺灣者，請詢求附近醫院進行醫療檢驗。
Sign in to Google to save your progress. Learn more
Email *
姓名Name(as shown on passport)
 *
一戶家庭僅須派一位代表填寫即可
e-mail
 *
現居地址(宿舍地址) Current Address (Dorm Address)
 *
您目前是否處於居家隔離或自主健康管理期間? Are you currently in the situation of home-isolation or self-health monitoring?
 *
目前是否有同住家人(或室友)因確診而居家隔離中? Do you have relatives/roommates(live with you) who diagnosed Covid and are in home-isolation?
 *
目前是否有同住家人(或室友)為確診者的密切接觸者而正在居家隔離中? Do you have relatives/roommates(live with you) who are close contact with confirmed case and are in home-isolation?
 *
您是否已打滿三劑疫苗? Have you completed all 3 shots of vaccines?
 *
僅為調查，不會影響參與權益。It will not influence your participation.
備註Note
You have answered all questions, and confirm that all the information you provide here is true and accurate. If any information or statement you provide is inaccurate or incorrect, we have the right to disqualify your application.
 您已完整回答所有問題，且確認所有您在此提供的資料皆為真實且準確。您亦理解到，倘若您所提供的任何資料或聲明是不準確或有誤時，我們保有取消資格的權利。
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of 南臺科技大學. Report Abuse
Google Forms