南臺科大  新冠病毒_確診者  疫調單
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Email *
一、基本資料Basic information
姓名Name *
學號 ( 教職員：請填無 )Student ID (Staff & Faculty: please fill in none) *
系所+班級 (教職員請填 系所／單位／職稱)Department/Class (For faculty members, please fill in Department/Unit/Title) *
電話號碼 Phone number *
二、
快篩 陽性日期Rapid screening positive date *
MM
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DD
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YYYY
快篩陽性後 視訊/就醫 日期 (如:5/1採檢，待結果；或 5/3 採檢，5/4(+)  )Video/medical appointment date after (+)rapid test(eg: May 1 testing, pending results; or May 3 testing, confirmed Covid-19 on May 4) *
(此題可不填 This question can be left blank)  出現時間&症狀 (例如: 5/3出現發燒、喉嚨癢痛、咳嗽、腹瀉等)Time & symptoms (for example: May 3 have fever, sore throat, cough, diarrhea, etc.)
(此題可不填 This question can be left blank)症狀發生或確診前2日 到現在，你的校園足跡為何?(例如： F104教室、教務處、圖書館、S棟7-11，W棟美食街、六宿學餐…等等) From the onset of symptoms or 2 days before the diagnosis to the present, what is your campus footprint? (For example: classroom F104, Academic Affairs Office, library, 7-11 in Building S, Food Street in Building W, Dorm 6 Cafeteria Meals, etc.)
列出你的同寢室室友(或寫無)。(只需列出本校學生，含班級／學號／姓名，以分號分隔，例：行流一甲／4a55555／王曉明；行流一乙/4a77777/蔡筱英；…….等等)List your roommates or fill none. (Just list the students of STUST, including class/student number/name, separated by semicolons, for example: Xingliu A/4a55555/Wang Xiaoming; Xingliu A/4a77777/Cai Xiaoying, etc.) *
請列出其他校內密切接觸者，並註明身分(或寫無)。(您於「確診或症狀發生前2日」到現在，您有摘下口罩與他們共同活動15分鐘以上，如共食、運動、唱歌等。包括本校教師、學生、教練等。例如: 學生／行流一甲／4a55555／王曉明;教師／劉大牆/體育中心；…等等)Please list other close contacts on campus and indicate their identities(or fill none). (You have taken off your mask and participated in activities with them for more than 15 minutes, such as eating, exercising, singing, etc. from the "2 days before the diagnosis or the onset of symptoms" to the present. This includes teachers, students, coaches, etc. of STUST. For example: students/ Xingliu Yijia/4a55555/Wang Xiaoming; Teacher/Liu Daqiang/Sports Center, etc.) *
如果您方便，可以留下您的line ID 方便我們疫調，若不願意，可以不用留 If it is convenient for you, you can leave your line ID to facilitate our epidemic investigation. If you don't want to, just ignore it.
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