國立臺灣大學健康關懷問卷（校外人士使用）

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)： 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 年(Year) 1 2 3 4 5 6 7 8 9 10 11 12 月(Month) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 日(Day)

填表日期(Date)：2024/4/20 上午 07:18:16

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 ?

否(No)

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 ?

否(No)

三、工作性質（Occupation）郵差(Postman)快遞(Delivery man)物流（Logistics）外包廠商（Outsourcing Companies）學員（trainee）旁聽（auditor）其他（Others）

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 ?

否(No)

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

否(No)

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.

本人已閱讀過以上說明，且願意配合防護措施及個人資料之提供(I certify that I have read the information above and will cooperate with the NTU preventive measures and have consented to provide my personal data.)

本人聲明以上所有資訊（含個人資料）均正確無誤，如有不實，本人了解須負民事、刑事及行政等相關法律責任。(I certify that all above statements (including my personal dada) are correct. If there is any false statement, I understand that I shall take all legal liabilities therefrom.)