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

All Persons are REQUIRED to wear surgical mask within CIC premises
在議會範圍内,所有人士須佩戴外科口罩

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
Staff 職員 Candidate 考生 Outsourced Staff 外判商 Visitor 訪客
Staff Number 職員編號
(if applicable 如適用)
Work / Visit Location
工作 / 到訪地點
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
Mobile Phone No 手提電話號碼

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

1. I am contracting with COVID-19 / undergoing HK government compulsory quarantine or isolation order
我正感染2019冠狀病毒病 / 正接受香港政府強制檢疫或隔離令 (Note備註1)*
2. I am having fever 我正在發燒 (Note備註1)*
3.
For the past 14 days I have/ have been 於過去14天我曾: May choose more than one options 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 曾到訪國家
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
c. In close contact with person who return 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 2 備註2) *
4. All of the above not applicable 以上各項皆不適用
Note備註1: Person who contracting with COVID-19 / undergoing HK government compulsory quarantine or isolation order/ having fever is not allowed to enter CIC premises. Alternative work / training / trade testing arrangements will be made by the CIC management. To safeguard the health for all persons within CIC premises, CIC reserves the right on the final decision of not allowing any person to enter CIC premises.
現正感染2019冠狀病毒病/ 接受香港政府強制檢疫或隔離令 / 有發燒徵狀之人士均不得進入議會範圍, 議會將會在工作 / 補課 / 補考方面另作安排。為保障所有進入議會人士的健康, 議會亦保留最終決定權, 拒絕任何人士進入議會範圍。
Note備註2: Persons shall stay quarantined for 14 days (starting from the relevant date as provided). Alternative work / training / trade testing arrangements will be made by the CIC management. To safeguard the health for all persons within CIC premises, CIC reserves the right on the final decision of not allowing any person to enter CIC premises.
須進行隔離檢疫14天 (由所提供的相關日期起計算), 議會將會在工作 / 補課 / 補考方面另作安排。為保障所有進入議會人士的健康, 議會亦保留最終決定權, 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. If you fail to provide all information, 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。若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。