For those who had close contact with the person with COVID19 infection.
※If you work at Chiba University hospital, or a student of medical training, please follow the instructions from infection control team of CUH.
Please copy the followings, and describe the contents. Please send it to the Nurse's Office of the Safety and Health Organization Chiba-Univ. Please contact us by e-mail at first.
| Contact Reason | Had Close contact with COVID-19 patient |
| Today's date | Year/Month/Date |
| Faculty Department | Where you belongs to? |
| ID number | 8 digits of alphabet numbers |
| Are you a Staff or a Student | Staff/Student |
| Name | Name （pronounciation in hiragana literature if possible） |
| Contacting |
Telephone number E-mail address Where you live（city and town name） |
| When was your last entering date of Chiba-Univ. | year/month/date |
| Do you have any symptoms? Yes/No | If Yes, please tell us the date and the description of your symptoms. Date:2022/month/date Symptoms in details please: |
| When was your last contacting date (接触日) with the person with COVID-19 infections. |
Year/Month/Date |
| Please tell the contacting situation. (接触状況) | Were you wearing mask, inside/outside of rooms, with many people or not, etc, please tell. |
| Relationship with the person with COVID-19 infection | Is the person Chiba-University participants, or your family members, or your friend? |
| If the patient is Chiba-University staffs and students, please tell us whom. | Name ※It relates for the public absences. |
| Have you went abroad, recently? Yes/No |
If yes, please write when and where you went. Date: Country Name: |
| Do you belongs to any activities in Chiba-Univ.? Yes/No |
If yes, please tell the name and the latest activity date. Activity Name: Date: |
| Have you taken a medical consultation? Yes/No |
If yes, please tell us the date and the medical institution name. Consultation date: Medical institution Name: |
| Antigen testings | Done/ Not done Result（ ）Testing date(year/month/date) |
| PCR testings | Done/ Not done Result（ ）Testing date(year/month/date) |
| Did you had any contact from the national health center Yes/No |
If yes, please tell us the name of the health center. Name: |
| Quarantine place and quarantine period. (Home/Hotels/etc.) |
Please tell us where you stay, and the period. If you have any direction from the health center, please let us know. Quarantine place: Quarantine period:(year/month/date) Direction from the health center: |
Living environment. Do you live alone by yourself, with someone or in the dormitory? |
Please tell whether you live alone, with your family or a roommate, or in the dormitory. |
| Have you done the COVID19 vaccin? Vaccinated/Not vaccinated |
How many times have you vaccinated? When was your last booster shot? Times: The last date: (year/month/date) |
| 1st booster shot | year/month/date （vaccine name:physer/moderna/etc.） |
| 2nd booster shot | year/month/date （vaccine name:physer/moderna/etc.） |
| 3rd booster shot | year/month/date （vaccine name:physer/moderna/etc.） |
| Free spaces | Please tell us about your allergies, vaccinated more than 4 times, or anything. |
Nurse's office in Safety and Health Organization ナース室
Email: info-hsc（アットマーク）office.chiba-u.jp
please change （アットマーク）to "@"
Tel: 043-290-2214