1. Basic information Name: Class: Tel: Date of birth: township (town, street), village (community) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
2. 14 the day before the history of epidemiology returned to school, did you have the following situation?
1. Have you ever gone abroad or left this country? If yes, please specify the countries and regions you have been to:
2. Have you been to the key areas of the original epidemic situation such as xx Province or other areas where local cases of pneumonia in novel coronavirus continue to spread?
3. Have you ever been in contact with patients with fever or respiratory symptoms from key areas such as xx province or other areas where local cases continue to spread? 3.
My health monitoring before returning to school (to be filled in from the date of receiving the declaration notice), date, temperature measurement record and cough health code.