Vendor/Customer/ Guest health declaration form
□廠商 Vendor □ 客戶 Customer □ 來賓 Guest
公司名稱 Company：
廠商/客戶人員姓名 Name：
連絡電話 Tel：
填單日期 Date：
健康狀況聲明：
健康狀況聲明：(以下日期均為填單日開始計算)
1. 近 14 日內是否曾有出國紀錄?
Have you ever gone abroad during the past 14 days?
□ 是 Y □ 否 N (若是則不可進入本公司 If Y, do not enter the WAFER WORKS)
2. 近 14 日內是否曾接觸過新型冠狀病毒肺炎確診案例?
Have you ever contacted COVID-19 confirmed cases identified by CDC during the past 14 days ?
□ 是 Y □ 否 N (若是則不可進入本公司 If Y, do not enter the WAFER WORKS)
3. 近 14 日內是否曾密切接觸過來自疾管署旅遊 日內是否曾密切接觸過來自疾管署旅遊管制國家名單(1~3 級)中近 14 日內入境人士?
Have you ever contacted people come back from List of Regulated Countries during the past 14 days?
□ 是 Y □ 否 N (若是則不可進入本公司 If Y, do not enter the WAFER WORKS)
4. 請勾選目前個人健康狀態是否有 請勾選目前個人健康狀態是否有 個人健康狀態是否有以下症狀?
Do you have any symptoms in the following list at this moment?
□ 發燒額溫 ≧ 37.5℃ (不可進入公司)
Do you have fever(Forehead temperature ≧ 37.5 ℃)? (If Yes, do not enter the WAFER WORKS)
□ 上呼吸道症狀 Do you respiratory symptoms?
(若是則不可進入本公司 If Yes, do not enter the WAFER WORKS)
□ 以上皆無 None of the above
新型冠狀病毒肺炎防疫期間 新型冠狀病毒肺炎防疫期間 狀病毒肺炎防疫期間－廠商/客戶/來賓 自主健康聲明書
COVID-19 Health Declaration Form for Vendor and Customer
「新型冠狀病毒肺炎」疫情擴大且國內出現人傳人案例，參酌我國疾病管制署之防疫建議，廠商及客戶請配合重新填寫健康聲明書，近 14 日內曾進出或曾接觸公司公告管制地區者，應配合公司防疫管理辦法。近 14 日內旅遊史、接觸史、曾進出醫學中心、區域醫院及地區醫院或健康狀況有變更者，請主動更新此健康聲明書。
In light of COVID-19 cases continue to grow and the Taiwan Centers for Disease Control (Taiwan CDC) has confirmed the domestic human-to-human transmission case. In accordance with Taiwan CDC,visitors and vendors must cooperate to re-fill in the“Employee COVID-19 Health Declaration Form”.
For people who have been to or contacted with restricted area defined by CDC or WAFER WORKSduring the past 14 days, must comply with WAFERWORKS epidemic prevention actions. Please fill in the health declaration form compulsively if any changes on your histories in your travel, contact, health status, medical center/regional hospital or district hospital visits during the past 14 days.
如您開始填寫並送交健康聲明書者，視為同意個人資料保護聲明內容所載之蒐集、處理及利用個人資料告知事項。
Upon your submission of the COVID-19 Health Declaration Form indicates that you have consented to the contents set forth in the Protection of Personal Data Announcement regarding the personal data collection, processing, and use.