海東國小老師用傳染病通報表單
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班級 *
座號 *
姓名 *
醫師診斷傳染性疾病名稱(例如:腸病毒.水痘.新冠確診........) *
備註欄
傳染病經醫師確診日 *
MM
/
DD
/
YYYY
班上"本周內"是否有"相同"診斷的個案(群聚事件)? *
是否住院或在家休養 *
目前症狀(就其知悉的勾選即可...........) *
Required
如果可以的話，請簡述發生經過
(或直接複製貼上家長聯繫傳染病內容即可)
備註欄
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