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彰化縣永靖國小109學年下學期學生及其家人寒假期間出國史(含1月6日至19日醫院感染事件)
班級如無出國史也請填無
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1. 年級
*
1
2
3
4
5
6
2.班級
*
1
2
3
4
5
6
7
3.本班級學生及家人寒假期間是否出國
*
無
有
4.座號
Your answer
5.姓名
Your answer
(承上題)學生本人或家人
Your answer
6.班上學生或其家人為【1月6日至19日醫院感染事件相關範圍之(一)出院病患及其同住者、(二)陪病者及其同住者、(三)案889就醫時之相關接觸者】所列居家隔離或自主健康管理對象清單
*
是
否
(承上題)有請填入班級座號
Your answer
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