Aide Code / 護理編號:

Last 4 Digit Social Security Number / 社安號最後4位:

Do you have any of the following / 你有沒有以下任何一項:

• (1) COVID-19 symptoms in the past 14 days (Fever, chills, cough, shortness of breath, sore throat, loss of taste or smell). / 在過去 14 天中出現了 COVID-19 新冠症狀(發燒，發冷，咳嗽，呼吸急促，喉嚨痛，味覺或嗅覺喪失)。

• (2) positive COVID-19 test in the past 14 days; and / 在過去 14 天中，COVID-19 新冠測試呈陽性；和

• (3) close contact with confirmed or suspected COVID-19 case in the past 14 days. / 在過去的 14 天中與確診或疑似 COVID-19 新冠病例密切接觸。

Yes / 有No / 沒有

我清楚並且同意如果有任何變化, 有任何疑似新冠病徵，或接觸過確診的人, 會立刻隔離自己並且跟公司聯絡 / I understand and attest that if there are any changes to my health condition, if I experience any of the COVID-19 related symptoms, or if I have had contact with someone who tested positive for COVID-19, I will isolate myself and notify Golden Touch immediately.
I agree / 我同意