EDB Health Declaration Form -WMA (Term 3)

2019 Coronavirus Disease (COVID-19) Declaration Form

2021-22 Term 3

Name of School*

Name of Child*

First Name

Last Name

Class*

Sex*

Male Female

Part A - Travel history of your child outside Hong Kong in the past 14 days*

My child has not been away from Hong Kong in the past 14 days prior to returning to school campus. My child has travelled outside Hong Kong in the past 14 days prior to returning to school campus.

Departure from Hong Kong*

Arrival in Hong Kong*

Destination (Please specify countries and cities)*

Part B - Whether your child has confirmed infection of COVID-19*

My child has not confirmed infection for COVID-19 My child has confirmed of COVID-19 infection and has already recovered.

Date of previous COVID-19 infection *

e.g. date of positive nucleic acid test/rapid antigen test result

Date of recovery *

e.g. date of discharge from hospital or recovery date certified; if no date specified, the 14th day after positive test result will be assigned as the recovery date.

Part C - The person taking care of or living together with my child*

Has not confirmed infection for COVID-19. Has confirmed infection for COVID-19 and has recovered. Has confirmed infection for COVID-19 and is still receiving treatment hospital. Has confirmed infection for COVID-19 and has been discharged from the hospital and taking medicine. Has not been classified as "close contact of an infected person"* of COVID-19.

*In general, close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and body fluids of a confirmed patient.

Relation with my child (Please specify)*

Part D - Current health status of your child*

My child has no symptoms of cough, shortness of breath, breathing difficulty and sore throat.

Name of Parent / Guardian *

First Name

Last Name

Parent Email*

Signature of Parent / Guardian*

[clear]

Use your mouse or finger to draw your signature above

Date