Skip to main content
General Education Team, CEDARS, The University of Hong Kong
You are here
Home
[HKU Students/Staff] Health Screening Form for Coronavirus Disease (COVID-19): Gatherland Booking
Submitted by
beatrice
on Mon, 03/29/2021 - 16:44
[HKU Students/Staff] Health Screening Form for Coronavirus Disease (COVID-19)
Gatherland Booking
Please complete the following form.
Section 1 Personal Information
Name of the Event/Programme to be attended
*
Event Date
*
Full Name in English
*
University No. / Staff No
*
HKU Portal Email Address
*
Contact No. (Mobile)
*
Accommodation
*
Home
Hall
Others
For others, please specify.
Others
Section 2 Do you have any of the following symptoms? 閣下有沒有以下病徵?
1. Fever 發燒
*
Yes
No
2. Cough 咳嗽
*
Yes
No
3. Breathing difficulty 氣促
*
Yes
No
4. Sore throat 喉嚨痛
*
Yes
No
5. Runny nose / blocked nose 流鼻水 / 鼻塞
*
Yes
No
6. Myalgia 周身骨痛
*
Yes
No
7. Diarrhoea 腹瀉
*
Yes
No
8. Recent onset of loss of smell or taste 最近開始喪失嗅覺或味覺
*
Yes
No
Section 3 Travel and Contact History 外遊及接觸史
1. In the past 14 days, have you left Hong Kong? 過去14天內, 閣下有沒有離開香港?
*
Yes
No
If yes, please answer questions A-C.
A. If yes, please specify countries visited 請註明到訪國家:
B. Please specify cities visited 請註明到訪城市:
C. Please specify duration of stay 請註明逗留日期:
(from 由:______ to 至 ______)
2. Did you have contact with any person who is suspected of, or confirmed to have COVID-19? 閣下有沒有與疑似或證實感染2019冠狀病毒病的人接觸?
*
Yes
No
Section 4 Declaration
Declaration
*
Yes
I declare that all the above information provided (including medical and travel history) is true and accurate, and will be responsible for any consequences arising from any false information if provided. 本人確認以上所有由本人提供的資料乃正確無誤，並承擔因提供虛假資料（包括病歷及外遊記錄）而產生的任何後果和責任。
