Construction Industry Council 建造業議會
Health Declaration Form 健康申報表

All Persons with Red Code Vaccine Pass will be DENIED ENTRY to CIC premises
所有持紅碼疫苗通行證人士均不得進入議會範圍

Part A 甲部(Please “√” in the appropriate box 請於適當的方格內「√」)

Visit Date 到訪日期
Name 姓名 Email 電郵
Status 身份
Candidate 考生 Outsourced Staff 外判商 Visitor 訪客 (必要性*) Visitor 訪客 (非必要性%)
Staff Number 職員編號
(if applicable 如適用)
Work / Visit Location
工作 / 到訪地點
Mobile Phone No
手提電話號碼
Department 部門
(for CIC staff only 議會職員專用)
Name of Residential Building
居住大廈名稱
Residential District 居住地區
e.g. Wong Tai Sin / 黃大仙
*Attend meeting (by CIC invitation) / apply registration of Worker 出席會議 (由議會邀請出席) / 辨理工人註册人士
% Person to attend / join CIC public event 參觀 / 與議會舉辦之公眾活動人士

Part B 乙部(Please “√” in the appropriate box 請於適當的方格內「√」)

1. I am infected with COVID-19
我正感染2019冠狀病毒病 (Note備註1)*
2. I am having fever
我正在發燒 (Note備註1)*
3. I am undergoing HK government("Government") compulsory quarantine / testing or isolation order or restriction-testing declaration
我正接受香港政府(「政府」)強制檢疫/檢測或隔離令或限制與檢測宣告 (Note備註1)*
4. For the past 7 days I have visited overseas places or Taiwan 於過去 7 天我曾到訪海外地區或台灣: (Note 備註 2)**
Please provide date of return 提供返港日期
4.
For the past 14 days I have/ have been 於過去14天我曾: May choose more than one Option 可選多於一項
a. Visited outside HKSAR 到訪香港境外地區
Date of Return 返港日期
Visited Country/ Place 曾到訪國家/ 地方
Visited City 曾到訪城市
b. In close contact / living with person with confirmed COVID-19 跟確診感染2019冠狀病毒病人士有緊密接觸/同住
Last Contact Date 最後接觸日期
b. In close contact with person who returned to HKSAR during the past 14 days 跟過去14天內返港人士有緊密接觸
Last Contact Date 最後接觸日期
d. Living in the residential building with confirmed case 居住於出現確診個案的大廈
CHP Announcement date 衛生防護中心公佈日期
(Note備註2)**
5. I am in close contact / living with persons confirmed COVID-19
跟確診感染2019冠狀病毒病人士有緊密接觸/同住 (Note備註3)***
6. I am living in a building with confirmed cases in the past 14 days
我正居住於過去14天出現確診個案的大廈 (Note備註3)***
5. All of the above not applicable 以上各項皆不適用
*Note備註1: Persons who contract COVID-19 / are undergoing government compulsory quarantine / testing or isolation order or restriction-testing declaration/ having fever are not allowed to enter CIC premises.
現正感染2019冠狀病毒病 / 接受政府強制檢疫/檢測或隔離令或限制與檢測宣告 / 有發燒徵狀之人士均不得進入議會範圍。
**Note備註2: Persons shall follow CIC Entry Requirement and Restriction for Vaccine Pass.
須跟從進入議會場地對疫苗通行證之要求及限制
***Note備註3: Relevant persons must complete all government required medical surveillance (if applicable) and be able to show "Negative" result from Rapid Antigen Test Kit for the day of entering to CIC premises. (Attention: This is not applicable to CIC iHub. Persons are not allowed to enter CIC iHub exhibition centres, virtual tour is available as an option).
相關人士必須完成政府要求的醫學監察(如適用), 並出示當天的快速抗原測試的'陰性'測試結果. (注意: 本項不適用於建造業展覽中心。相關人士將不得進入建造業展覽中心範圍,但可選擇參加「虛擬導賞」)。
Note備註3: Alternative or additional anti-pandemic work / training / trade or certification testing arrangements will be made by the CIC management. To safeguard the health for all persons within CIC premises, CIC according to the government latest requirements reserves the right on the final decision of not allowing any persons to enter CIC premises.
議會將會在工作 / 訓練 / 工藝或資歷證明測試方面另作或增加其他防疫安排。為保障所有進入議會人士的健康, 議會將按照政府最新要求保留最終決定權, 拒絕任何人士進入議會範圍。
I declare that all the above information is true, and I consent to the uses of my personal data as described in the Personal Information Collection Statement below.
本人聲明以上申報內容全部屬實,並同意按下文之收集個人資料聲明所述使用本人的個人資料。

Personal Information Collection Statement: The data you provided shall be used for precautionary measures against infectious disease. CIC reserves the right to collect / verify all relevant information (not limited to PART A&B, e.g. notification / information from LeaveHomeSafe). If you fail to provide all the information required, you may not be allowed to enter CIC's premises. The data is provided of your own free will for the above purpose. You, or any representative who is authorized by you in writing, are entitled to make a written request to inspect and correct all data you have provided. The information will be destroyed 4 weeks after the date of visit.

收集個人資料聲明︰閣下所提供的資料僅用於預防傳染疾病之用。議會保留權利收集/核實相關資料(不限於甲及乙部, 如:安心出行內的通知/資料),如閣下未能提供所有資料,則可能不獲准進入議會場所。閣下所提供的資料皆為閣下就上述目的而自願提供。閣下或閣下書面授權的代表均有權提出書面要求,以檢查及更正閣下所提供的所有資料。所收集的資料將於到訪日期起4星期後被銷毁。