StudentsDailyHealth Reporting学生每日健康问卷（英文版）-调查问卷模板-问卷网

I promise I will fill the bellowing form with true and accurate information and bear the correspondent responsibilities if I was covering up.

填表人承诺以下填报内容属实，如有瞒报、漏报、迟报、谎报等，愿意承担相关法律责任。

Agree 同意

What was the time when you are filling the form?

进行筛查的时间？

Morning 早晨

Evening 晚上

Your Name：

学生姓名

____________

Your current temperature:

您的体温

Normal正常(37.3℃)

Abnormal 体温异常(≥37.3℃) Please specify 请注明

Did you or will you leave Beijing today?

您今天有离开北京吗？

NO 没有离开北京

Yes and I haven’t leave.

Yes and I am on my way.

Yes and I have returned.

Your current location:

您的当前所在地

____________

Your co-resident(s) stay in Beijing today?

今天学生的所有同住人在北京吗？

I live alone

YES 在

NO 不在If NO, please specify the situation.如果离京，请具体说明

Do you or any of your co-resident(s) have the following symptoms？

学生或共同居住人是否有以下症状发生？

Fever 发热（≥37.3）

Cough 咳嗽

Sore throat 咽痛

Chest Tightness 胸闷

Difficulty in breathing 呼吸困难

Mild limbs/lower back muscle soreness/weakness/poor energy 轻度四肢/腰背部肌肉酸痛/乏力/精神稍差

Nausea, vomiting/diarrhea 恶心呕吐/腹泻

Headache 头痛

Tachycardia 心慌

Others 其他

None of above 无以上症状

In the past 14 days, have you or your co-resident(s) been in contact with persons who are back to Beijing from abroad ？

在过去的14天内，学生或共同居住人是否接触过从境外来京人员？

NO 没有

YES 有If yes, please specify the details: person, date and Vehicle (Flight No.).如果有，请注明人员，日期和交通方式(航班号)。

In the past 14 days, have you or your co-resident(s) travelled from medium-risk or high-risk areas to Beijing?

在过去的14天内，学生或共同居住人是否从国内中、高风险地区返京？

NO 没有

YES 有If yes, please specify the details: person, date and Vehicle(Train No./Flight No./Car No.)如果有，请注明人员，日期和交通方式(火车号/航班号/车牌号)。

Do you have any visitors from other cities in China today?

今天你的家庭中有京外人员到访吗？

NO 没有

YES 有If yes, please specify the details: person, date and Vehicle(Train No./Flight No./Car No.)如果有，请注明人员，日期和交通方式(火车号/航班号/车牌号)。

StudentsDailyHealth Reporting学生每日健康问卷（英文版）

相关模板