0424-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。
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姓名Name(as shown on passport) *
e-mail *
現居地址/宿舍 Current Address/Dormitories *
過去30天內去過哪些國家（含港澳地區），如無可略過此題Please fill in all countries (including Hong Kong and Macao) you have been to during the past 30 days. (If no, you can skip the question.)
呈上題，近一次入境臺灣日期為? Following the previous question, please tell us the date of your last arrival into Taiwan.
如上題為無，可略過此題 You can skip the question if the answer is NO in the previous question.  
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您是否接受過新冠肺炎篩檢?Have you received a COVID-19 screen test? *
承上題，如有請填篩檢日期，篩檢醫療院所與結果，如無可略過此題 If yes, please fill in the date when the test was taken, the medical institute, and the results. (If no, you can skip the question.)
您是否曾與感染新冠肺炎病患接觸？Have you ever in any physical contact with the COVID-19 patients ? *
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? *
您是否已施打疫苗 Have you been vaccinated yet?
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