Declaration Form for Student's Travel History and Health Status

Declaration Form for Student's Travel History and Health Status
Student Name:*

First NameLast Name
School Division

Early YearsPrimarySecondary
Class
Class
Tutors
Your Child's Recent Travel History
Is your child currently located in Hong Kong?*

YesNo
Where is your child currently located?*
Has your child travelled outside of Hong Kong in the 14 days prior to class resumption?*

YesNo
Where has your child travelled to?*
Date of their departure from Hong Kong:*

DayMonthYear
Date of their arrival in Hong Kong:*

DayMonthYear
Your Child's Recent Health
Has your child been confirmed with an infection of COVID-19*

YesNo
Has your child recovered from COVID-19?*

YesNo
Hospitalised: From *

DayMonthYear
To*

DayMonthYear
Date that your child tested Negative:*

DayMonthYear
Additional Info:
Has your child been classified as being a "close contact¹ of an infected person with COVID-19"?*

YesNo
¹ In general, close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and bodily fluids of a confirmed COVID-19 patient
Date of contact with infected person:*

DayMonthYear
The Recent Travel History of the People Caring for your Child
Is there any member of the household that is currently under 14 day home quarantine'?*

YesNo
Date of their departure from Hong Kong:*

DayMonthYear
Date of their arrival in Hong Kong:*

DayMonthYear
Details of the country/countries they have recently visited:*
Does the person under 14 day home quarantine have any of the following symptoms: fever, cough, shortness of breath, breathing difficulties, sore throat, malaise (generally unwell), loss of sense of taste and/or smell?*

YesNo
The Recent Health Status of the People Caring for your Child
Have any of the people taking care of your child or living with your child been confirmed with an infection of COVID-19?*

YesNo
Has any of the people taking care of your child or living with your child recovered from COVID-19?*

YesNo
Hospitalised: From*

DayMonthYear
To*

DayMonthYear
Relation to your child:*
Additional info:
Have any of the people taking care of your child or living with your child been classified as being a close contact¹ of an infected person with COVID-19?*

YesNo
¹ In general, close contact means having cared for, having lived with, or having had direct contact with respiratory secretions and bodily fluids of a confirmed COVID-19 patient
Relation to your child:*
Date of contact with infected person:*

DayMonthYear
Do any of the people taking care of or living with your child work in an occupation where they may be placed under medical surveillance?*

YesNo
Occupation:*
I understand that if my child develops any of the following symptoms then they shall not attend school and shall consult a doctor: fever, cough, shortness of breath, breathing difficulties, sore throat, malaise (generally unwell) and loss of sense of taste and/or smell. *
I understand that if a member of the household is placed into ‘14 day home quarantine’ then I shall inform the school. *
I understand that in the case of any confirmed infection of COVID-19, students and/or their parents/persons living in the same household should NOT return to school and have to notify the school immediately. *
Name of Parent/Guardian:*

TitleFirst NameLast Name
Parent/Guardian's Email:*
Parent/Guardian's Signature:

Clear
Date:*

DayMonthYear
Please note - Health and Travel information provided may be passed on to the Centre of Health Protection (CHP) when necessary to facilitate outbreak investigation and implementation of control measures
Should be Empty:

Declaration Form for Student's Travel History and Health Status

Your Child's Recent Travel History

Your Child's Recent Health

The Recent Travel History of the People Caring for your Child

The Recent Health Status of the People Caring for your Child