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.
* 1. 工號 Employee ID (ex. v00001)
* 2. 請選擇體溫測量方式 Please select body temperature measurement method
額頭溫度計 (≧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)
腋下溫度計 (≧37.5℃視為有發燒症狀) Underarm thermometer (≧37.5℃ considered as fever)
* 3. 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 783-120)
* 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?
是 Yes (將關閉公司通行權 You will be prohibited from entering all VisEra areas within Taiwan)
* 4.1 是否已施打COVID-19疫苗? Have you got the COVID-19 vaccination?
已施打 ( 請立即更新健康聲明書) Got vaccinated ( please update the health declaration form)
再次施打 ( 請立即更新健康聲明書) Got vaccinated again ( please update the health declaration form)
已施打並已更新健康聲明書 Vaccinated and update the declaration
未施打過 Not vaccinated
* 5. 近7日內，您或您的同住者(含非每日同住)是否因新冠肺炎疑似症狀而就醫?
Have you or your cohabitants (including non-daily living together) sought medical care for suspected symptoms of COVID-19 in the past 7 days?
是，本人 Yes, myself
是，同住者 Yes, cohabitants
若為是，請輸入最近一次就醫日期 If yes, please input the date of the last sought medical care (e.g. 2021/05/20)
勾選是者，請遵守以下規定 If yes, please follow the rules below
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.
* 6. 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?
是，收到實聯制警示通知 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
是，收到國家疫情警示簡訊通知且足跡時段重疊 Yes, received National epidemic alert newsletter and overlapped footprints
勾選是者，14天內需遵守以下規定 If yes, please follow the rules below within 14 days
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
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
* 7. 近7日內，您或您的密切接觸者曾接受PCR核酸採檢(依據最新一次檢測結果填答)?
Have you or your closely contacted with someone who accepted the PCR nucleic acid test in the past 7 days (According to the latest test result)?
結果陽性(確診) (將關閉公司通行權) Positive (confirmed case) (You will be prohibited from entering all VisEra areas within Taiwan)
以上皆非 None of above
* 8. 近7日內，您最近一次快篩結果為何?
What is your last rapid test result in 7 days?
未測試 Not tested yet
快篩陽後PCR結果為陰 Positive of rapid test but PCR result is negative
結果為陽, 請至最近的社區快篩站執行篩檢採檢 (將關閉公司通行權) Positive, please go to the nearest community rapid test station to perform screening (You will be prohibited from entering all VisEra areas within Taiwan)
最近一次測試日期 the last test date (e.g. 2021/05/20)
I have read the statement, and warrant the accuracy of the declaration.
員工體溫回報表 - 填寫完成!
Employee Self-check Body Temperature has Completed!
You have completed!