RU Inst. of Website Design

Epidemic investigation-COVID-19

1. (*) Consent answer to be used for research
   • Agree
   • Disagree
1. (*) student ID
2. Name
3. (*) gender
• male
• Female
4. (*) Contact phone
5. (*) Have you been abroad in the past 14 days Yes (please continue to fill in the place and time of departure abroad) No (not required)
2. 6. country
   Please fill in the country of departure and city name
3. 7. Return time
   Please fill in the return period:
4. 8. (*) Immigration or contact history
   Is there any entry or contact situation since 2020
   China, Hong Kong and Macao Entry (including transit from various countries via China, Hong Kong and Macau, please fill in the date in the remarks field) None
5. 9. Note
   Immigration or contact history (please fill in country and date)
6. 10. (*) Have you contacted relatives and friends who have returned to Taiwan in the past month? No (not required)
7. 11. Note
   Date of contact with relatives and friends returning to Taiwan from abroad
8. 12. (*) Current health
   • Have a fever
   • Have a cough
   • Have chest tightness, asthma symptoms
   • Have a confirmed or suspected case history
   • Other discomforts (please fill in other discomforts below)
   • No (normal health)
9. 13. Other discomfort
   My current health status (please fill in)
10. 14. (*) Is there an autonomous health management situation? None
11. 15. Autonomous health management period
    Date ~ date
12. 16. other
13. 17. (*) Is this questionnaire filled out for me
    If it is not true, it shall bear its own legal responsibility.
    Yes 否