Health Declaration Form – Student Prize Presentation Ceremony 2021 Student Number 學生編號*Salutation 稱謂*Mr 先生Miss 小姐Ms 女士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*Have you completed the full COVID-19 vaccination course (receiving two doses at least 14 days ago)? 閣下是否已完成接種2019冠狀病毒病疫苗 (起碼14日前完成接種兩劑疫苗)? *Yes 是No 否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 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. NextThis Health Declaration Form CAN ONLY BE SUBMITTED ONCE. Please ensure that the answers provided in the form are correct.Are you sure you want to submit the form? If you are not sure, please press ‘Back’ and return to the form.BackSubmitThis field should be left blank
