EmailMeForm
Registration Form for Employee Rework
In order to prevent and control pneumonia caused by new coronavirus, please take a few minutes to complete the investigation.
1. Your name
*
First
Last
2. Your job number
*
3. Department
*
4. Your current location
*
Address
Longitude
Latitude
5. Your planned rework date
*
MM
/
DD
/
YYYY
6. In the past two weeks, have you used the following transportation?
*
Please select
Aircraft
Train
Bus
Steamship
Carpool
Other
7. In the past two weeks, have you travelled, transferred or stayed in Hubei Province?
*
Please select
Via Hubei (please fill in the city)
Transfer in Hubei (please fill in the city)
Stay in Hubei (please fill in the city)
No
Please fill in the city
*
8. In the past two weeks, have you had the following situations?
*
Please select
Have contacted relatives and friends from Hubei (please fill in the city)
People who have been exposed to fever, dry cough, fatigue, and dyspepsia
None of the above
Please fill in the city
*
9. Recently, do your family members have symptoms such as fever, dry cough, fatigue, and difficulty breathing?
*
Yes
No
10. Do you need the company to provide help related to the epidemic?
*
Yes (please elaborate)
No
Please elaborate
*
