國立臺灣大學健康關懷問卷(校外人士使用)

[NTU] Severe Special Infectious Pneumonia (COVID-19) Prevention Form (For Visitors)

***為因應Covid-19疫情之防疫需求,本校蒐集進入本校校園之校外人士之個人資料,均係根據傳染病防治法、學校衛生法等法令,以及主管機關教育部、中央疫情指揮中心之要求,敬請如實填寫以下資料,違者恐違反傳染病防治法第三十六條及第七十條有關防疫檢疫措施之規定,將遭處新臺幣三千元以上一萬五千元以下罰鍰。
***Please fill in the following information honestly. According to the Articles 36 and 70 of the Communicable Disease Control Act, the person who violates the law may be fined by 3,000 to 15,000 NTD.
姓名(Name):

請填下列任一證件資料(Please fill in the ID/ARC number):
身份證或居留證字號(ID/ARC Number):  

電話號碼(Phone Number):
生日(Birthday): 年(Year) 月(Month)日(Day)
填表日期(Date):2020/5/31 下午 03:39:35

請注意,若欲順利進入本校館舍,以下旅遊史、追蹤措施、接觸史、是否群聚皆須為「否」,並完成本問卷,且如有不實填報,須負民事、刑事及行政等相關法律責任;如您有任何項目為「是」,請您放棄填寫問卷,待狀況解除後再行填寫。
Attention! In order to enter any NTU buildings, you have to check "No" in the following questions of Travel history, Follow-up Measures, Contact history, and Cluster. If you do not respond honestly, you shall take all legal liabilities therefrom. Please give up filling this questionnaire if you can not honestly check "No" in the aforementioned items.
一、 旅遊史(Travel history)
請問您過去14天內,是否有從國外任何地區入境而未完成14天居家檢疫,或曾經前往有群聚/確診者活動而經本校公告14天內不到校上班上課之國內地點?
Do you escape from 14 days of home quarantine if entering Taiwan from any foreign countries, or have you been to any domestic places declared by NTU as indiscriminately subject to a 14-day absence on the campus ?
二、追蹤措施(Follow-up Measures)
請問您是否因任何原因,正在進行14天居家隔離、居家檢疫、或自主健康管理中?
Are you currently undergoing 14 days of home isolation, home quarantine, or self-health management ?
三、工作性質(Occupation)
四、接觸史(Contact history)
請問您過去14天內是否有接觸從國外回台之人士 ?
Have you had contact with people who entered Taiwan from foreign countries in the past 14 days ?
五、是否群聚(Cluster)
請問您過去14天內身邊是否有其他2人(含)以上出現下列疑似感染症狀?
發燒症狀 (額溫≧37.5℃)、咳嗽、流鼻水、鼻塞、喉嚨痛、頭痛、呼吸急促、肌肉痠痛、疲倦、味覺或嗅覺喪失、腹瀉
Are there more than 2 people (including 2 people) around you having the following symptoms in the past 14 days? fever (forehead temperature over 37.5℃) , cough, runny nose, stuffy nose, sore throat, muscle pain, headache, fatigue, diarrhea, shortness of breath, loss of sense of taste or smell

本校係依相關醫療及防疫法令,基於公衛或傳染病防治、保健醫療服務及其他法定義務之目的蒐集、處理、利用以上個人資料,您可依個人資料保護法第三條規定行使相關權利,本校將依個人資料保護法就以上個人資料進行妥善保護。您同意並瞭解本校蒐集、處理或利用個人資料之目的及用途。
According to the Medical Care Act and relevant epidemic prevention regulation, National Taiwan University(NTU) will collect, process and use the above personal data to meet the purpose of public health and communicable disease control, health and medical services and the other legal duties. You are entitled to exercise the related rights according to Article 3 of Personal Data Protection Act. NTU will properly protect the above personal data in accordance with Personal Data Protection Act. You have consented and understood the purpose of collection, processing and use of the personal data from NTU.