Notices
ENGLISH >> News >> Notices
Letter of Commitment: Epidemiological Survey and Data Collection at Centralized Quarantine
Updated:2020-02-15   Hits:   Font size:[Large] [middle] [Small]

 

I promise, my answers to the following questions are true and effective. If I was found to cause a spread of the novel coronavirus due to information withholding, I am willing to take the correspondent legal responsibilities.

Promiser                Passport (ID) number:

Cell.                   Date:

Have you had the exposure history in the last 14 days before being confirmed infection or being tested positive :

1. Have you had the travel or living history in Wuhan or the surrounding areas, or communities with confirmed cases?

£ Travel history  living history   £ No

2. Have you had any contact with the people who came from Wuhan or the surrounding areas, or patients who have fever or respiratory symptoms from communities with confirmed cases?

£ Yes  £ No

3. Have you had any contact with the people who came from Wuhan or the surrounding area, or people who have travel or living history from communities with confirmed cases?

£ Yes  £ No

4. Have you had any contact with the confirmed cases or the asymptomatic infected people?  

£ Yes  £ No

5. Do your affiliated collective units including family, employing unit, childcare institutions, school and etc have the clustering occurrence of infection?

£ Yes  £ No   Not clear

6. Have you visited the clinic recently?

£ Yes  £ No

7. Are there any farmers markets in your place of residence (villages/residential buildings)?

Yes, about ___ meters from your home.  No Not clear

8. Have you been to the farmers markets?

£ Yes  £ No   Not clear

If you have gone to the farmers markets, the patient was: Marketing Personnel, Supplier or purchaser, consumer, other (including people who deliver meal, look for someone and pass by etc.)