力成科技『嚴重特殊傳染性肺炎健康聲明書』62.0版 PTI “Health Declaration Form” for COVID-19
本人特此聲明本健康聲明書所填寫內容皆正確屬實，填寫後若有任何情事更新或改變（如接觸史或健康狀況有變更），本人了解有義務自主更新健康聲明書內容，並告知主管，若填寫不實或隱匿疫情未通報，本人了解，依照傳染病防治法及相關法令，本人恐遭主管機關裁罰，本人並同意賠償力成科技因此所受損害。 The undersigned hereby declares that the information disclosed herein is true and to the best of my knowledge. If the information disclosed herein has any change or update after this declaration is signed (such as the contact history or health condition), I understand that I have the obligation to update my Health Declaration Form and inform my supervisors or managers. If the information provided is false or there is any failure to disclose the required information, I understand that I will be held accountable for the liability of violating Communicable Disease Control Act the relevant laws and regulations of local authorities and might be subject to fines and penalties, and I agree to compensate PTI for any and all losses and damages resulting from such violation.

*1 .手機電話 (Telephone Number)

*2 .請問您最近7天內是否有呼吸道感染疾病?

Have you had any respiratory infections in the last 7 days?




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