心連心事工 - 健康申報表 Reconnect Ministry - Health Declaration Form
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本機構致力為到訪朋友、案主、及員工提供健康安全環境。煩請到訪者到達本機構時填妥健康申報表。如閣下未能填妥本表格或確認本表格所列出的事項，閣下將不能進入本機構。感謝閣下的配合。Reconnect Ministry is committed to providing a safe environment for our clients and staff. Please complete this form upon your arrival. You will not be allowed to attend our office if you fail to complete this form or confirm the matters as set out in this form. We appreciate your cooperation.
本人申報、聲明及同意如下 (請剔同意項目):I hereby declare and agree that (please tick where appropriate ):
1. 本人現時及過去 14 日內並無以下任何症狀，包括發燒、乏力、乾咳、呼吸困難或感冒症狀。I do not have and have not had in the past 14 days any of the following symptoms - fever, malaise, dry cough, shortness of breath or other flu-like symptoms. *
2.本人在過去 14 日內並無離開香港。 I have not been out of Hong Kong in the past 14 days. *
3.本人並未曾與在過去 14 日內曾離開香港的任何人士有密切接觸，尤其是家人、家庭傭工及司機。I have not been in close contact with any person who have travelled outside Hong Kong in the past 14 days, in particular family members, helpers or drivers. *
4. 本人在過去 14 日內並未曾與任何(i)新型冠狀病毒確診人士或(ii)懷疑確診人士或(iii)以上人士的緊密接觸者(無論在香港或海外)有密切接觸。I have not been in close contact with any person who is (i) a confirmed or (ii) preliminary positive case of Novel Coronavirus (COVID-19) infection or (iii) their close contacts (in Hong Kong or overseas) in the past 14 days. *
5. 本人居住大廈沒有新型冠狀病毒確診個案。There is no confirmed COVID-19 cases in the building where I live. *
6. 本人聲明據本人所知及所信，以上資料均屬正確無誤，並同意機構根據其《私隱政策聲明》 (https://www.hkreconnect.org.hk/privacy-policy) 處理及使用本人所提供資料。 I confirm that the above information is accurate to my best knowledge and agree that such information will be processed and used in accordance with Reconnect Ministry’s Privacy Policy Statement (https://www.hkreconnect.org.hk/privacy-policy). *
重要提示 : 任何到訪者/案主故意提供虛假或誤導性資料均嚴重違反聲明協議，機構保留追究權利。 IMPORTANT: Any visitor/client who knowingly provides false or misleading information is in serious breach of this Declaration and Reconnect Ministry reserves the right to make any legal claim against you.
活動參加者名字 Participant's Name： *
香港身份證(頭4數字) HKID(first 4 digits)： *
(若參加者未滿十八歲)填寫表格人士名稱及與參加者關係：
聯絡Contact： *
日期Date: *
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核對負責人 Person in charge verifying： *
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