Health Report

1. Report date *

Year

Month

Day

2. Your name *

First name Last name

3. Your e-mail address *

4. Category of Student *

Host Research Unit Professor *

Rearch Unit Administrator(RUA)'s email address *

Host student's name *

5. Have fever of 37.5 ℃ or higher? *

Yes

What's your temperature? *

6. Have any symptoms of COVID-19 including cough, soar throat, respiratory symptoms, strong feeling of weariness (fatigue)? *

Yes

Please write your symptom(s) *

7. Action of the day *DO NOT go out unnecessarily *

e.g. Went to the convenience store for grocery shopping

What code is in the image? *

Enter the characters shown in the image.

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