Contractor Health Declaration Form

Dear Sir/Madam

As a precautionary measure to reduce the risk of exposure of our guests/visitors to the 2019-Novel Corona virus situation (2019-nCov), we would appreciate if you complete this form. Your participation is important to help us take precautionary measures to protect you and everyone in the Club. Thank you for your time

Worker's Name 員工姓名 *

Company Name 公司名稱 *

Contact Number 聯絡電話 *

Company’s Responsible Person/Phone Number 公司負責人/聯絡電話 *

If your answer to any of the questions (1) – (6) is “Yes”, you may not be granted access to the club. 如問題(1) – (7)的回答為[是], 閣下可能不會獲准進入會所.
SELF-DECLARATION 健康申報

1. Are you currently having a fever or any flu symptoms such as coughing, runny nose, sore throat? 您目前有沒有發燒或其他流感病徵,如咳嗽, 流鼻水, 喉嚨痛? *

Yes 有
No 沒有

If Yes, number of days 如有, 日數

2. Have you been in contact with a confirmed COVID-19 patient in the past 14 days? 過去14天內，你是否曾與確診新型冠狀病毒的患者接觸？ *

Yes 是
No 否

3. Are you waiting for a COVID-19 test result? 是否正等待新型冠狀病毒測試結果? *

Yes 是
No 否

4. Have you had any confirmed case in your residential building in the past 14 days? 過去14天內, 你所居住的大廈是否有新型冠狀病毒確診個案? *

Yes 有
No 沒有

5. Have you travelled to places other than Mainland China, Macau and Taiwan in the past 21 days? 過去21天內,你是否曾到訪中國大陸、澳門及台灣以外地方？ *

Yes 是
No 否

Date of entry to Hong Kong 入境香港日期 *

6. Have you been in close contact with any person who has travelled to places other than Mainland China, Macau and Taiwan in the past 21 days? 你是否與在過去21天內曾到訪中國大陸、澳門及台灣以外地方的人士接觸？ *

Yes 是
No 否

7. Have you travelled to Mainland China, Macau or Taiwan in the past 14 days? 過去14天內,你是否曾到訪中國大陸、澳門或台灣？ *

Yes 是
No 否

Date of entry to Hong Kong 入境香港日期 *

8. Have you been in close contact with any person who has travelled to Mainland China, Macau or Taiwan in the past 14 days? 你是否與在過去14天內曾到訪中國大陸、澳門或台灣的人士接觸？ *

Yes 是
No 否

9. Have you received the COVID-19 vaccination? 你有否接種2019冠狀病毒病疫苗？ *

Yes 是
No 否
Prefer not to answer 不願回答

Checkboxes *

I hereby declare that all information given above is correct and accurate, and to the best of my knowledge. 本人特此聲明，上述提供的資料為本人所知悉的範圍內及準確無誤。

Providing false or misleading information to club management will be subject to denied access to the club. We are collecting personal data for the purposes of enabling us to carry out contact tracing and other response measures, with regards to any emergency that may arise due to COVID-19 that may threaten the health or safety of other individuals. The Club reserves the right whenever appropriate to refuse entry to any person who has travelled abroad within the past 14 days or has any symptoms of illness or has been in close contact with anyone who has travelled abroad in the past 14 days.

向會所管理層提供虛假或誤導性信息將不獲准進入會所。由於2019年新型冠狀病毒可能會威脅其他人的健康或安全，我們正在收集個人數據，以便進行追踪和其他跟進措施，應對因2019年新型冠狀病毒引起的任何緊急情況。會所保留在合適的情況下拒絕任何人進入會所。

Contractor Health Declaration Form

If your answer to any of the questions (1) – (6) is “Yes”, you may not be granted access to the club. 如 問題(1) – (7)的回答為[是], 閣下可能不會獲准進入會所.SELF-DECLARATION 健康申報

If your answer to any of the questions (1) – (6) is “Yes”, you may not be granted access to the club. 如問題(1) – (7)的回答為[是], 閣下可能不會獲准進入會所.
SELF-DECLARATION 健康申報