菲特中国企业复工人员情况登记表 FCNResuming Work Employee Information Collection

您的姓名 Your Name

您的性别 Your Gender

您的年龄 Your Age

您的身份证号 Your ID Number

您的户籍地 Place of Household Registration

现居住（南京）地详细地址 （填写格式： XX 市 XX 县/区 XX乡 XX 街道 XX号 ）Your current detail address in Nanjing

您的联系电话 Your Phone Number

您有无发热、咳嗽、呼吸困难等身体不适症状? Do you have any symptoms such as fever, cough and dyspnea?

请您描述具体症状 Please describe your detail symptom

1月25日之后您是否离开过南京 Have you leave Nanjing since Jan. 25th?

您离开南京的具体日期 The detail date you leave Nanjing

您返回南京的具体日期 The detail date you return back to Nanjing

您的民族 Your Nationality in China

您是否是孕妇？Are you pregnant？

您是否为武汉市民？Are you citizen from Wuhan？

您是否在机场、火车站、汽车站、港口客运站乘坐过交通工具？Have you ever taken transportation at the airport, train station, bus station, or port terminal?

请填写您的具体乘坐的车次/航班号：Please describe detail train/flight number

请填写您乘坐车次/航班的始发地 Please fill in your train / flight origin：

请填写您乘坐车次/航班的目的地 Please fill in your train / flight destination：

来宁前14天内，您是否有发热、呼吸道症状患者接触史 Have you ever contacted patients with fever and respiratory symptoms in 14 days before you come to Nanjing？

来宁前14天内，您是否有新型冠状病毒感染的肺炎病例接触史？Have you ever contacted infected patients with 2019-nCoV in 14 days before you come to Nanjing？

您是否有发热症状？Do you have fever symptoms?

您发热时最高体温为多少℃？What is your maximum temperature when you have a fever?

您是否有乏力、干咳、胸闷的现象？Do you have fatigue, dry cough, or chest tightness?

您是否有咳嗽现象？Do you have a cough?

您是否有其他不适症状？Do you have any other symptoms?

其他不适症状具体描述 Please describe symptom detail here