Health Declaration Form – MAGAZZIN GROUP INTRANET

Staff ID*

員工編號 X-XXXX

Full Name (English)*

全名（英文）

Email Address*

電子郵件地址

Department*

部門

Staff Type*

員工類別

Sales 銷售
Operation 辦公室

Declaration Item

申報項目

Do you have any of the following symptoms? **

你有否以下徵狀？

發燒 Fever
氣促 Shortness of breath
咳嗽 Cough
呼吸困難 Breathing difficulty
以上皆無 None of the above

If you have tick yes to any of the symptoms, do you have a medical certificate to confirm your sickness is not related to the flu or Covid-19?*

假如你出現以上症狀，是否能提供醫生紙作證明你已排除流感或新型冠狀病毒感染的可能？

有 Yes
沒有 No - 請立即求診 Go see doctor
不適用 N/A

For the past 14 days, have you been in contact with any family members or other persons who under compulsory home quarantine, or anyone suspected of or have been diagnosed with Covid-19?*

過去14日你有否與家居檢疫人士, 懷疑或確診感染新型冠狀病毒之人士或親屬接觸?

有 Yes
沒有 No

Any “Confirmed Cases” of COVID-19 within their respective places of residence: If Yes, pls list out the place

在其各自居住地內的任何COVID-19的“確診病例”：如果是，請列出該位置

I declare that all the above information is true.*

我確保以上申報內容全部屬實。

是 Yes

The personal data provided will be used by MAGAZZIN Group Limited for the purpose of preventing the occurrence or spread of an infectious disease or contamination. You are required to provide the personal data to achieve the above-mentioned purpose. The personal data you provide may be disclosed to Government bureaux/departments for the above mentioned purpose, if required. You have a right of access and correction with respect to personal data as provided. Please contact your department or HR for enquiries concerning the personal data.*

你向名家集團有限公司提供的個人資料是用於預防任何傳染病或污染的發生或蔓延。你有責任提供此表格要求的個人資料以達到上述目的。你所提供的個人資料，在有需要的情況下，可能會向政府決策局/部門或相關機構披露以作上述用途。你有權查閱及修正你提供的個人資料。如欲查詢有關你所提供的個人資料，請聯絡你所屬部門或人力資源部。

同意 Agree

Remark

備註

Health Declaration Form 健康申報表

Declaration Item