TOPFIVE 防疫調查問卷 Epidemic Prevention Questionnaire

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學員姓名 Name *

身份別 Identity *

學員 member

教練/工作人員 coach

試上學員 experienced course members

報名班級 (請打上LINE群組的班級/教練請填寫教練) Belongs to which class? (for example: Wednesday 16: 30-18: 00) *

請問過去 14 天內，是否有從國外任何地區入境而未完成 14 天居家檢疫，或曾經前往有群聚/確診者活動而經本校公告 14 天內不到校上班上課之國內地點？ Do you escape from 14 days of home quarantine if entering Taiwan from any foreign countries, or have you been toany domestic places declared by NTU as indiscriminately subject to a 14-day absence on the campus ?

是 Yes

否 No

Clear selection

請問過去 14 天內是否有接觸從國外回台之人士？Have you had contact with people who entered Taiwan from foreign countries in the past 14 days ?

是 Yes

否 No

Clear selection

請問過去 14 天內身邊是否有其他 2 人(含)以上出現下列疑似感染症狀？發燒症狀 (額溫≧37.5℃)、咳嗽、流鼻水、鼻塞、喉嚨痛、頭痛、呼吸急促、肌肉痠痛、疲倦、味覺或嗅覺喪失、腹瀉 Are there more than 2 people (including 2 people) around you having the following symptoms in the past 14 days?fever (forehead temperature over 37.5℃) , cough, runny nose, stuffy nose, sore throat, muscle pain, headache,fatigue, diarrhea, shortness of breath, loss of sense of taste or smell.

是 Yes

否 No

Clear selection

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