上海中学国际部健康登记表 SHSID Health Form

为了您与他人的健康与安全,请在递交材料前,完成下面问卷调查。谢谢您的配合! For the health and safety of you and others, please complete the following questionnaire before submitting the materials. Thank you for your cooperation!
1.
家长姓名/国籍Full name/Nationality of parent(s):*
2.
学生姓名/国籍/申请年级 Full name/Nationality of student(s)/Apply for Grade:*
3.
家长身份证号/护照号/港澳通行证号 Your ID Card No./Passport No./HK Macao Permit No.*
4.
您在沪的居住(暂住)地址(XX路XX弄XX号XX室)Your Permanent (Temporary) Residential Address in Shanghai*
5.
工作单位名称 Company name:*
6.
手机号Your Mobile Phone Number:*
7.
过去两周内,是否离开过上海?Have you left Shanghai in the past two weeks?*
8.
目的地及回沪日期 (Destination and date back to Shanghai)*
9.
过去两周内,是否前往《重点区域》出差、探亲、旅游? In the past two weeks, have you been to <the key epidemic area> for business trip, visiting or travelling?*
10.
过去两周内,是否乘车、乘机、乘船从《重点区域》换乘 In the past two weeks, have you been transferred from <the key epidemic area> by car, plane or boat?*
11.
过去两周内,是否所乘火车、汽车、飞机、船舶在《重点区域》经停(经停期间有人员上下车)In the past two weeks, is the train, car, plane, or boat you've been embarked that stopped in <the key epidemic area> (people get on and off during the stop)?*
12.
过去两周内,是否与有《重点区域》旅行、出差、途经、居住史的亲戚、朋友、客户等有过密切接触 In the past two weeks, have you been in the close contact with relatives, friends, customers who have travelled or lived in <the key epidemic area>?*
13.
过去两周内,是否与确诊病例和疑似病例有过密切接触 In the past two weeks, have you been in the close contact with confirmed and suspected cases?*
14.
如果您的家属(指居住在一起的家属)身体有异常情况,请您登记有异常情况的家人数。 Number of your family members who stay together with abnormal conditions.*
15.
本人目前健康状况(可多选)My current health condition (multiple options available) :* 【多选题】
16.
本人承诺以上填报信息真实准确,并自返沪之日起按照政府要求执行自我观察、自我隔离等措施。如有身体不适,将第一时间上报。如有不实,本人将承担相应的后果及法律责任。I hereby promise that the information provided above is true and accurate, and will implement self-observation, self-isolation and other required measures in accordance with government requirements from the date of return. I will report to the related organization immediately if feeling unwell. In case the information provided is not true and accurate, I will bear the corresponding consequences and legal liabilities.*
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