Survey for Departure and Arrival in Taiwan during 2020 Winter Break

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Please assist us with the survey in order to provide the epidemic prevention for the outbreak of 2019-nCoV, which was first identified in Wuhan, Hubei Province, China. The new 2019-nCoV has resulted in more than a thousand confirmed cases in China, including cases outside Wuhan City. Your assistance will be greatly appreciated!
*必填

Name: *

Employee ID: *

Gender: *

Male

Female

Prefer not to say

Office: *

Position: *

Year(s) at NCKU: *

1 year or less

1-2 years

3-4 years

4-5 years

5-6 years

6-7 years

7+ years

Country of Residence/Citizenship: *

Have you departed from Taiwan during 2020 winter break? *

Yes, I left Taiwan during 2020 winter break.

No, I stay in Taiwan during 2020 winter break.

I left Taiwan for a short period of time during 2020 winter break; however, I have already returned to Taiwan.

I am a new teacher at NCKU and I will be in Taiwan for NCKU 2020 spring semester.

Have you ever visited to China, Hong Kong or Macao during winter break (included flight transfer at China, Hong Kong or Macao airport)? *

Yes

N/A ( If you did not leave Taiwan )

Required

Country(ies) visited or layover on this trip prior to Taiwan arrival ( Please mark N/A if you did not leave Taiwan ): *

If country(ies) you visited include Mainland China, please specify city(ies) name, thank you ! ( Please mark N/A if you did not leave Taiwan or went to Mainland China ) *

Date of Taiwan arrival or expected date of Taiwan arrival (Please mark N/A if you did not leave Taiwan. Please indicate '' Will Not Return'' if you do not plan to return to Taiwan.) *

Health symptom(s) during 2020 winter break : *

Fever over 37.5 ˚C

Cough

Sore throat

Short of Breath

Running nose

None of the above

Required

Current state of health: *

Normal/healthy

Need to be observed/Undetermined at this moment

Are you an identified case of home quarantine by the authority of Taiwan?( or Have you ever been) *

Yes

Have you ever in any physical contact with the 2019-nCoV patients ? *

Yes

Dormitory/Accommodation for 2020 spring semester: *

Dormitory provided by NCKU

Accommodation outside of NCKU

Please provide your email address: *

Please provide your cell phone number : *

Comments:

Declaration: *

By checking the box, I hereby certify that the above information provided is true and correct to the best of my knowledge and belief and I understand that I subject myself to disciplinary action per Taiwan Ministry of Health and Welfare, Communicable Disease Control Act, Chapter 6: Penal Provision in the event that the above facts are found to be falsified.

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