Name: Gender:
Admission ticket number: work unit:
ID number: valid mobile phone contact information:
My address before the exam 14 days (please fill in details, please indicate the street/community and house number or hotel address):
1. Did I have fever, dry cough, fatigue, stuffy nose, runny nose, sore throat, diarrhea and other symptoms within 14 days before the exam? □ Yes □ No.
2. Am I a confirmed case and asymptomatic infected person in COVID-19? □ Yes □ No.
3. Whether it was isolated within 14 days before the exam or isolated at the place of residence without nucleic acid detection. □ Yes □ No.
4. Whether you entered Shandong from high-risk areas outside the province within 14 days before the test. □ Yes □ No.
5. Did you enter Shandong from abroad (including Hong Kong, Macao and Taiwan) within/0/4 days before the exam? □ Yes □ No.
6. Did I enter Shandong from Xinjiang and Yunnan within/0/4 days before the exam? □ Yes □ No.
7. Whether I have contact history with confirmed cases, suspected cases or asymptomatic infected persons in COVID-19 within 14 days before the test. □ Yes □ No.
8. Is there any contact history with overseas personnel (including Hong Kong, Macao and Taiwan) within 0/4 days before the exam? □ Yes □ No.
9. Me? Health code? Whether it is a non-green code. □ Yes □ No.
10.*** Is there a ratio of 1 8 among family members living together? □ Yes □ No.
Tip:
1. What is the item above 1- 10? what's up Yes, the negative report of novel coronavirus nucleic acid test must be within 7 days before the test.
2. It is suggested to reduce unnecessary trips, not to have dinner or get together, wash hands frequently and wear masks correctly within 0/4 days before the exam.
I promise: I will truthfully fill in the health declaration card item by item. If the spread of quarantine infectious diseases is caused by concealment or false reporting, or there is a serious risk of spread, which affects public safety, I will bear corresponding legal responsibilities and voluntarily accept the punishment and sanctions of People's Republic of China (PRC) Criminal Law, Law on Public Security Administration Punishment, Law on the Prevention and Control of Infectious Diseases, and Opinions on Punishing Crimes that Hinder the Prevention and Control of Epidemic in novel coronavirus according to Law.
My signature:
Completion date:
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