Name 姓名 *

First Name

Last Name

Have you been fully vaccinated (3rd doses completed) against COVID-19? 您是否已完全接種新冠疫苗(已完成第3劑) *

Yes 是

No 否

Have you or anyone you live with, arrived in Hong Kong from overseas (including Macau and Mainland China) in the past 14 days? 您本人或您家中的成員於過去14日內是否曾由外地返港(包括澳門及中國內地)? *

Yes 是

No 否

Have you been in close contact with someone who is on Mandatory Home Quarantine from the Centre For Health Protection, or have been issued one? 您是否與衞生署要求之家居隔離人士有密切接觸?或您是否為家居隔離人士? *

Yes 是

No 否

Are you currently experiencing fever or respiratory symptoms (cough, sore throat, runny nose, flu, shortness of breath etc.) or have had any such symptoms in the past 14 days? 您於現時，或過往14天是否有發燒或呼吸道感染症狀(咳嗽、喉嚨痛、流鼻水、氣喘等等)? *

Yes 是

No 否

Have you been infected with COVID-19? 您是否曾感染過新型冠狀病毒病? *

Yes 是

No 否

I hereby declare that I have answered the above questions truthfully and to the best of my knowledge. 我承諾以上為真實答案。 *