MEDICAL DECLARATION FOR PARTNERS 1.Personal information Passport Full name Phone number Body temperature (degrees C) E-mail Career Company name Person involved in infection (F1, F2, F3, ..., Unrelated) 2.Temporary / residential address information Nation Province / city District Address 3. Information to or from an area with Covid-19 infection or in a quarantine caused by a Covid-19 infected person (within the past 21 days) Lao CaiHa NoiHai PhangGia LaiBac GiangBinh DươngHoa BinhKhanh HoaThanh HoaVinh PhucPhu ThoQuang NinhHai DuongBac NinhOther places (Outside of the above provinces) Places you have moved within the past 21 days (specify, address, Commune / Ward, District / District, Province / City) 4.Symptom information (within the past 21 days) FeverA coughShortness of breathSore throatVomiting / nauseaDiarrheaExternal bleedingSkin rashI have no symptoms of covid-19 5.Exposure history (say within the past 21 days) Contact with an infected / suspected person with COVID-19People from epidemic areas in the countryPeople returning from epidemic countriesGo to a farm / live animal market / animal slaughter facility / animal contactContact with foreigners from epidemic countries (China, Korea, Japan, Iran, UK, Italy, ....)During the past 21 days I have not been exposed to the source of covid-19 infectionF2
