JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
吳興國小111學年度第一學期<學生>自行接種covid-19疫苗回報
親愛的家長您好:
為確實瞭解本校孩童完成新冠疫苗接種情形,若家長有帶孩童於校外完成疫苗接種,請隨時利用表單回報校方,謝謝您的配合。
健康中心關心您
Sign in to Google
to save your progress.
Learn more
* Indicates required question
班級
*
Your answer
座號
*
Your answer
學生姓名
*
Your answer
接種劑別(兩劑皆自行接種者,請分開回報,謝謝)
*
第一劑
第二劑
追加劑
疫苗廠牌
*
輝瑞兒童BNT
莫德納半劑
成人BNT
莫德納全劑
接種日期
*
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of 吳興國小.
Report Abuse
Forms