Declaration form for travel history and health status of students (Proforma B)

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2021년 1학기 홍콩한국토요학교 Korean Saturday School H.K.

Please complete the below form and submit (Please put a “ √ ” in the appropriate box)

성명 등 한국어로 작성하셔도 됩니다.

Name of Student : *

Class : *

Sex: *

Required

Part A – Travel history of your child outside Hong Kong in the past 14 days *

My child has not been away from Hong Kong in the past 14 days prior to class resumption (If you tick this answer, no need to answer (A-1) to (A-2).)

My child has paid visit outside Hong Kong in the past 14 days prior to class resumption (If you tick this answer, you need to answer (A-1) to (A-2).)

Required

(A-1) Duration: From___①___ (Month)___②___ (Day) (Departure date) To___③___ (Month)___④___ (Day) (Arrival date)

(A-2) Destination (Please specify countries and cities) : ________________________________

Part B – Whether your child has confirmed infection of COVID-19 *

My child has not confirmed infection for COVID-19(If you tick this answer, no need to answer (B-1).)

My child has confirmed of COVID-19 infection and has already recovered. (If you tick this answer, you need to answer (B-1).)

Required

(B-1) Hospitalization Period: From___①___ (Month)___②___ (Day) To___③___ (Month)___④___ (Day)

Part C – Health status of those taking care of your child, or those living with your child *

Person taking care of or living together with my child has not confirmed infection for COVID-19.(If you tick this answer, no need to answer (C-1).)

Person taking care of or living together with my child has confirmed infection for COVID-19.(If you tick this answer, you need to answer (C-1).)

Person taking care of or living together with my child, has not been classified as “close contact of an infected person”* of COVID-19. (* In general, close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a confirmed patient.)

Required

(C-1)Person taking care of or living together with my child has confirmed infection for COVID-19, the person

Part D – Current health status of your child *

My child has no symptoms of cough, shortness of breath, breathing difficulty and sore throat.

My child has symptoms of cough, shortness of breath, breathing difficulty and sore throat.

Required

Name of Parent/Guardian: *

Date: (dd/mm/yyyy) *

Submit

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