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. 

If you have taken the self-test with the antigen test kit, please attach a photo of your student ID card, also a clock showing the date and the time of the test. Please also indicate the name of the manufacturer and the part number of the antigentest kit.

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)

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.
Symptoms in details please:     
When was your last contacting date (接触日)
with the person with COVID-19 infections.
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?

If yes, please write when and where you went.
Country Name:    
Do you belongs to any activities
in Chiba-Univ.?
If yes, please tell the name and the latest activity date.
Activity Name:
Have you taken a medical consultation?
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
If yes, please tell us the name of the health center.
Quarantine place
and quarantine period.

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
Vaccinated/Not vaccinated

How many times have you vaccinated?
When was your last booster shot?
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)  
    please change (アットマーク)to "@"
  Tel:    043-290-2214