The information you provide will be used by the Authority for the purpose of preventing the occurrence or spread of infectious disease. The information provided will be treated in strict confidence and will not form part of your personal data held by the Authority.
你所提供的資料將會被本局用於預防傳染病的發生或蔓延。有關資料將會被嚴加保密，並不會被本局保留作為你的個人資料。

Name (in full) 姓名：

1. Have you travelled to other city or country within the past 14 days?  你過去14天內是否到訪過其他城市或國家?
Yes 是No 否

If yes, please specify the dates and city / country  如有，請列明日期及城市 / 國家:

2. Have you been in close contact with someone who travelled to other city or country within the past 14 days? 你曾否於過去14天内與到訪過其他城市或國家的人士有密切接觸?

Yes 是No 否

If yes, please specify the city visited by the person and the date of your last contact with that person  如有，請列明該人士曾到訪的城市及你最後與該人士接觸的日期:

3. Have you been in contact with person with suspected or confirmed COVID-19? 你曾否接觸疑似或確診2019冠狀病毒感染人士?

Yes 是No 否

I declare that all the above information is true. 我保證以上申報內容全部屬實。