Health Declaration Form – Student Prize Presentation Ceremony 2022

ALL awardees and guests must observe the infection control measures in force and the Vaccine Pass policy of the University. (https://covid19.hku.hk/control/hku-vaccine-pass/).
Anyone wishing to enter the campus will be asked to use the LeaveHomeSafe mobile application to scan the campus QR code. The LeaveHomeSafe mobile application should have one’s vaccination record or exemption certificate installed.
Guests will also be asked to use the LeaveHomeSafe mobile application to scan the Grand Hall QR code before entering the event venue. They should show the Vaccine Pass to the QR Code Verification Scanner devices for checking and recording.

Student Number 學生編號*

Full English Name 英文全名 (As printed on identity documents / 與身分證明文件上相同) *

Contact number (mobile) 手提電話號碼*

PART A – Symptoms in the past 7 days 過去7日出現的徵狀

Have you experienced any of the following symptoms in the past 7 days?
在過去7日有沒有出現以下徵狀?

Fever 發燒*

Yes 有

No 沒有

Cough 咳嗽*

Yes 有

No 沒有

Breathing difficulty 氣促*

Yes 有

No 沒有

Sore throat 喉嚨痛*

Yes 有

No 沒有

Runny nose / blocked nose 流鼻水 / 鼻塞*

Yes 有

No 沒有

Myalgia 周身骨痛*

Yes 有

No 沒有

Diarrhoea 腹瀉*

Yes 有

No 沒有

Recent onset of loss of smell or taste 最近開始喪失嗅覺或味覺*

Yes 有

No 沒有

PART B – Travel and Contact History 外遊及接觸史

1. Did you stay outside Hong Kong during the past 21 days? 過去21日內，閣下有沒有離開香港?*

Yes 有

No 沒有

If yes, please specify countries and cities you stayed: 如果曾在21日內離開香港，請列出你所到過的國家及城市：

Countries 國家*

Cities 城市*

Please specify duration of stay (From when to when) 請註明逗留日期：（由XX月XX日至 XX月XX日）*

2. Have you been in physical contact with any person who is suspected of, or confirmed to have COVID-19? 閣下有沒有與疑似或證實感染2019冠狀病毒病的人接觸?*

Yes 有

No 沒有

PART C – Declaration*

I understand that anyone who wishes to enter any part of the HKU campus must comply with the HKU Vaccine Pass policy. 本人明白所有進入港大校園的人士必須遵守香港大學疫苗通行證政策。

I understand that anyone who wishes to enter any part of the HKU campus will be asked to use the LeaveHomeSafe mobile application to scan the campus QR code. The LeaveHomeSafe mobile application should have my vaccination record or exemption certificate installed. 本人明白所有進入港大校園的人士需要在校園入口掃瞄「安心出行」二維碼。本人需要將接種紀錄或醫學豁免證明書儲存至「安心出行」流動應用程式。

I understand that guests will also be asked to use the LeaveHomeSafe mobile application to scan the [ address TBC ] QR code before entering the event venue. I should show the Vaccine Pass to the QR Code Verification Scanner devices for checking and recording. 本人明白參加者需要在 [ address TBC ] 入口掃瞄「安心出行」二維碼。本人需要將疫苗通行證給處所的驗證二維碼掃瞄裝置進行查核及記錄。

I declare that all the above information provided is true and accurate, and will be responsible for any consequences arising from any false information. 本人確認以上所有由本人提供的資料乃正確無誤，並承擔因提供虛假資料而產生的任何後果和責任。

Personal Information Collection Statement

For more information about the Personal Information Collection Statements, please click here.

This Health Declaration Form CAN ONLY BE SUBMITTED ONCE.

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