2021旅樂食藝博覽暨國際學術研討會防疫健康關懷問卷
您好，為因應「嚴重特殊傳染性肺炎」疫情，請協助填寫下列資料，並詳細閱讀注意事項：
一、個資蒐集告知聲明事項：本研討會係依相關醫療及防疫法令，基於公衛或傳染病防治及其他法定義務之目的蒐集、處理、利用您的個人資料，您可依個人資料保護法第三條規定行使相關權利。
二、本研討會將依個人資料保護法就您的個人資料進行妥善保護，本表將由本研討會保存28天後進行銷毀。
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姓名 (Name) *
連絡手機 (Contact Cell Phone) *
最近14天內出境史 (Have you ever been to or transited through any of the following countries/regions in the previous 14 days?) *
最近14天內是否出現以下症狀(複選) Have you had any of the following symptoms in the previous 14 days? (Tick all that apply) *
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◆中央流行疫情指揮中心公布澳洲新冠檢驗陽性機師及本土個案(案1091、1112、1120、1127、1128、1129)之國內活動足跡如下所述，您是否於下列時間點出入下列地點(本土個案足跡依據2021/5/1中央流行疫情指揮中心公布資料更新)？ *
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最近14天內您或同住家人是否收到政府機關開立通知單(居家隔離通知書、健康聲明暨居家檢疫通知書、自主健康管理單)？Did you or your family members receive any Taiwan governmental notification in the previous 14 days?(e.g. Home Quarantine Notice, Novel Coronavirus Health Declaration and Home Quarantine Notice, and Self-Health Management Sheet)? *
您是否曾與感染嚴重特殊傳染性肺炎（COVID-19）病患有接觸？Have you ever had close contact with someone diagnosed with COVID-19 in Taiwan? *
您是否曾出入機場及其他頻繁接觸外國人場所？I have been to an airport, or a place(s) where foreigners gather. *
溫馨提醒：Reminder:
因應嚴重特殊傳染性肺炎疫情，希望您與會期間全程配戴口罩，不便之處敬請見諒。In response to the severe and special infectious pneumonia epidemic, we hope you will wear a mask throughout the conference. We apologize for the inconvenience.
A copy of your responses will be emailed to the address you provided.
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