Your filling in and
submission of the Employee Self-check Body Temperature Form
indicates that you have consented to the contents set forth in this
announcement regarding the personal date collection, processing,
and use. 同意
1. 工號 Employee ID (ex. v00001)
2. 請選擇體溫測量方式 Please select body temperature measurement method
(≧37.5℃視為有發燒症狀) Forehead thermometer (≧37.5℃ considered as fever) 耳朵溫度計
(≧38℃視為有發燒症狀) Ear thermometer (≧38℃ considered as fever)
(≧37.5℃視為有發燒症狀) Underarm thermometer (≧37.5℃ considered as fever)
體溫 Temperature (℃) (ex. 36.7)
If you have a
fever, please seek medical treatment as soon as possible and
notify your supervisor and wellness center(Wellness center
* 3.1 是否因施打COVID-19疫苗而發燒 Develop a fever
after a COVID-19 vaccination
若為是，請填入施打日期 If yes, Please input the
date of the vaccination (e.g. 2021/07/15)
3.2 症狀(可複選) Symptoms(Multiple choice)
提醒:下列選項為「非因施打疫苗而產生之症狀」Remind: The following checkboxes are
"Symptoms not caused by vaccination"
* 4. 是否有以下任一狀況, 若有屬高風險人員請立即更新 健康聲明書。 Do you have any following
conditions? If you are high risk person, please re-fill the health declaration form.
1. 近14日內是否曾有出國紀錄? Have you ever gone abroad in the past 14 days?
2. 近14日內是否為中央流行疫情指揮中心匡列為居家隔離者? Have you received a quarantine notification from CECC in the last 14 days?
For those who cohabitated with someone who enter from abroad or have closely contacted with someone who received quarantine notification from CDC in pass 14 days. (1) 同住員工其返台親友入境第8-14天居家檢疫期間，關閉采鈺公司通行權 VisEra entry permission of employee will be restricted during the 8th day to 14th day home quarantine of inbounders.
(2) 同住員工於進入公司前出示返台親友檢疫期滿前一次PCR陰性報告使可恢復采鈺公司通行權 VisEra entry permission of employee will be restored with the negative PCR report of the 13-14 day of inbounders before entering VisEra.
(3) 同住員工於返台親友入境第18及第21天各增加一次快篩，並於進入公司後出示快篩結果（快篩試劑領取詳見公告） Employee must show rapid tests using home test kits on the 18th day and 21th day of the inbounder's arrival day. (Follow the announcement to pick up the home test kits).
是 Yes (將關閉公司通行權 You will be prohibited from entering all VisEra areas within Taiwan)
否 No * 4.1 是否已施打COVID-19疫苗? Have you got the
( 請立即更新健康聲明書) Vaccinated and update the declaration (update when you get vaccinated again) ( please update the health declaration form)
and update the declaration
vaccinated * 5. 近7日內，是否收到以電話、App或簡訊方式通知與確診者足跡重疊?
Have you received notifications by phone, App or SMS that overlap
with the confirmed person’s footprint in the past 7 days?
Yes, received conduct name registration warning notice 是，收到台灣社交距離App警示通知
Yes, received Taiwan Social Distancing App warning notice
Yes, received National epidemic alert newsletter and overlapped
勾選是者，14天內需遵守以下規定 If yes, please follow the rules below within 14
1. 禁止參與面對面會議 Face-to-face meetings is prohibited
2. 同仁於個人辦公座位工作時，依然配戴口罩 Wear masks when working at your own office
seats 3. 請同仁獨立用餐 Have meal alone
如有發燒、呼吸道症狀，腹瀉，或嗅、味覺異常等疑似症狀，請就醫評估或可至社區篩檢站採檢 If you have fever,
respiratory symptoms, diarrhea, or abnormal smell, taste and other
suspected symptoms, please consult a doctor for evaluation or go
to a community screening station for examination
For COVID-19 cluster case of Taoyuan International Airport issue, if employee, cohabitants or close contacts work at Taoyuan International Airport, had been to Taoyuan International Airport or have overlapped the footprint of confirmed case in the past 14 days.
是，請填寫( 桃園機場群聚案自主健康聲明書申報) Yes, Please fill in the Taoyuan International Airport’s COVID-19 cluster case Health Declaration Form
I have read the statement, and warrant the accuracy of the
員工體溫回報表 - 填寫完成!
Employee Self-check Body Temperature has