COVID-19 (TOCC) Risk Assessment Form
1.Have you ever traveled to China in 14 days?
□Yes □No
2.Have any of your family living together traveled to China in 14 days?
□Yes □No
3.Have you traveled to other countries, except for China?
□Yes □No
4.Have any of your family living together traveled to other countries, except for China?
□Yes □No
5.Had you put on face mask during the whole trip?
□Yes □No □No traveling
6.Had your family living together put on face mask during the whole trip?
□Yes □No □No traveling
7.Have you had any of the following symptoms after traveling?
□Fever □Cough □Runny nose □Sputum □Sore throat □Muscle ache □None of the above □No traveling
8.Have your family living together had any of the following symptoms after traveling?
□Fever □Cough □Runny nose □Sputum □Sore throat □Muscle ache □None of the above □No traveling
9.Have you ever contacted anyone who has a fever or influenza-like illness?
□Yes □No
10.Have your family living together ever contacted anyone who has a fever or influenza-like illness?
□Yes □No
11.Does the person you have contacted, who has a fever or influenza-like illness, have the following symptoms?
□Fever □Cough □Runny nose □Sputum □Sore throat □Muscle ache □None of the above □No contact
12.Does the person your family living together have contacted, who has a fever or influenza-like illness, have the following symptoms?
□Fever □Cough □Runny nose □Sputum □Sore throat □Muscle ache □None of the above □No contact
13.Did you transit from China, Hong Kong or Macau to Taiwan?
□Yes □No