건강상태 확인서 발급기관 운영지침 (1-7판) 2020.10.01.

Application for Fit to Travel Medical Certificate

▣ Information (in English)

Given Names
Family Name
Nationality						Gender			◯ Male ◯ Female
Date of Birth						Destination (Country)
Passport number							Departure date
Mobile phone							Staff No. for KE staff only
Home Address
* Vietnam Please fill out only those who enter Vietnam.	Intended Address in Vietnam
	Date of Entry
확인서 발급구분		신속 LAMP PCR ( )	RT-PCR ( )	중국 PCR ( )	일본 PCR ( )			신속 항원 ( )				항체 검사 ( )
		하와이 PCR ( )	베트남 PCR ( )		KE 승무원 ( )			사번기재 (KE 직원한함)

※ Please check your passport information and complete it correctly. (Please fill in the same as your passport information.)

▣ Select the check box if the following is applicable for you. :

□Yes □ No	Have you ever been in traveling overseas in the last 14 days?	□Yes □ No	Have you ever visited the outbreak area of COVID-19 cases in the last 14days?
□Yes □ No	Do you have any respiratory symptoms (cough, sore throat,ect)?	□Yes □ No	Have you ever been in contact with confirmed(or suspected) COVID-19 cases in the last 14days?
□Yes □ No	Have you ever diagnosed with pneumonia of unknown cause by a doctor?	□Yes □ No	Have you ever attended the rally related to the COVID-19 outbreak in the last 14days?
□Yes □ No	Have you ever been tested positive for Corona-19 in the past?	□Yes □ No	Do you have any changes in diet, taste, and smell?
□Yes □ No	Have you ever visited the outbreak region or building of COVID-19 cases in the last 14days?
□Yes □ No	Fever ( above 37.5℃) ( BT : ℃ )		BP : / mmhg / PR :

Consent to Collection, Use and Provision of Personal Information
· (Purpose of Collection) certificate issuance · (Items to be Collected) name,passportnumber,mobile pone,date of birth,destination etc. · (Period of Retention) period of time within the range of retention period prescribed by the law. · (Right of Veto and Disadvantage)Due to the refusal to agree, you will not be disadvantaged in using the medical service provided by Inha University Hospital. In this case, the service, which requires personal information, may be delayed or not available.	[ ] I agree [ ] I do not agree

Application date : 20   .       .        .

applicant    :

Incheon International Airport Terminal 2

Airport Medical Center Inha Univ.