员工健康申报表
Employee Health Declaration Form

为有效防控新型冠状病毒感染的肺炎疫情,确保您和他人的健康,请您如实填报您近期的健康状况,非常感谢!
As one of the key measure to control the outbreak of nCoV and prevent each employee and his or her family's health, please declare your following information truthfully.
1.姓名 Name*
2.性别 Gender*
3.年龄 Age*
4.籍贯 Native place*
5.您在本市的居住地址:
Your  residence address in this city*
6.自2019年12月15日以后,是否有过武汉或其他湖北省城市的旅居史?如有,请填写城市名。
Have you ever travelled or lived in wuhan or any other city in Hubei province since Dec-15-2019? If yes, please also report which city.*
7.自2019年12月15日以后,有无接触过湖北省的亲戚、朋友、客户、供应商或其他人员?如有,填写最后接触日期。
Have you ever met realatives, friends, customers, suppliers or others since Dec-15-2019? If yes, please declare the last meet date.*
8.过去14天到现在,您是否有以下症状?
Do you have any of the following symptoms since last 14 days, if any, please click.*
9.自疫情以来,是否接触过有新型冠状病毒感染者或疑似病例? 如有,请填写最后接触日期。
Have been exposed to new coronavirus infections or suspected cases since since this nCoV outbreak? If yes, please declare the last exposure date.*

10.你返沪/返京后在居住房屋内有接触来自湖北省或者其它地区人员的可能性吗?如果有,请详细说明。

After your back Shanghai or Beijing, will you have close contact with people from Hubei Province or other provinces in your residence? If yes, please explain.*

11.你以及你的同住人在2019年12月15日以后,有正在被隔离或者隔离解除的情况吗?如有,请详细说明。

Since Dec-15-2019 have you or your co-resident is under isolation or isolated? If yes, please explain.


*

我已仔细阅读本申报卡所列事项,并确认以上申报内容准确真实。
I have carefully read the items listed in this declaration card and confirmed above declaration is accurate and true.
员工健康申报表Employee Health Declaration Form

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