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防範新型冠狀病毒肺炎自主健康聲明書 Novel Coronavirus Health Declaration Card
因應新型冠狀病毒肺炎疫情，參酌我國疾病管制署之防疫建議，須配合填寫自主健康聲明書。
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* Indicates required question
● 14日(含)內自其他國家或地區入境臺灣者及其同住親屬，請依規定進行居家檢疫或自主隔離。
● 配合安全管理，進入會場期間請自主配戴口罩，若額溫≧37.5 °C 者，將被禁止進入會場。
當您開始填寫後，即表示您已盡您所知完整回答所有問題， 且確認所有您在此提供的資料皆為真實且準確。
姓名 Name
*
Your answer
身分證號碼或居留證號碼 ID card No./Residence permit No.
*
Your answer
性別 Gender
*
男 Male
女 Female
其它 Other
電話 Telephone Number
*
Your answer
請問您過去 14 天是否有發燒、咳嗽或呼吸急促症狀？(已服藥者亦須填「是」) During the past 14 days, have you had fever, cough, or shortness of breath? (for those who had taken medications, please answer”YES”)
*
是 YES
發燒 Fever
咳嗽 Cough
呼吸急促症狀 shortness of breath
否 NO
Required
近 14 天內是否曾入境或過境其他國家或地區？ During the past 14 days, have you been to the following regions?
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是 YES (請在下面填入入境國家）
否 NO
Required
請填入曾入境或過境其他國家或地區 （沒有免填）
Your answer
1. 提醒大家加強勤洗手、呼吸道衛生與咳嗽禮節，保持良好個人衛生（如：打噴嚏、咳嗽需掩住口、鼻，擤鼻涕後要洗手）及妥善處理口鼻分泌物等。
2. 如有發燒或呼吸道症狀，均請主動與縣市衛生局聯繫或撥打防疫專線 1922。
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