防範新型冠狀病毒肺炎健康聲明書　Novel Coronavirus Health Declaration Card

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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，請各位貴賓配合填寫健康聲明書。
Please cooperate with the epidemic prevention measures of COVID-19 by CDC and fill out the health declaration

■14日(含)內本人或其同住親屬，自其他國家（地區）入境台灣者，或因政府相關公告須依規定進行居家檢疫或自主健康管理者，依照防疫規定辦理。
Please follow the epidemic prevention regulations if you or the relative you live with entered Taiwan from other countries(regions) within 14 days required by the government for home quarantine or self-health management.

■配合學校校園健康安全管理，進入校園需量測體溫，若額溫≧37.5度者，將被禁止進入校園；入校期間請配戴口罩，保持社交距離。
Under XINGYA health and safety management, everyone has to take body temperature at the entrance. Please do not enter the campus if your forehead temperature is over 37.5 degrees. Be sure to wear masks and maintain social distance at all times.

當您開始填寫，即表示您會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。
When you start to fill out, it means that you answer all the questions to your best knowledge and confirm all the information you provide is true and accurate.

姓名Name *

身分證號碼或居留證號碼ID card NO./ Residence permit NO. *

生理性別Physiological Gender *

男 Male

女 Female

手機號碼Cellphone NO. *

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 short of breath?(for those who have taken medicines, please answer ''Yes'') *

是 Yes

發燒 Fever

咳嗽 Cough

呼吸急促 Shortness of breath

其他 Others

否 NO

Required

近14天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? *

是 Yes

否 NO

請填寫14天曾入境或過境其他國家或地區(無則跳過此題).Please fill in if you have been to the following countries or regions during the past 14 days(Skip if no).

近14天是否去過政府公告之區域需要居家檢疫或自主健康管理?During the past 14 days, have you been to any government-announced region that requires home quarantine or self-health management. *

是 Yes

否 NO

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