For those who have symptoms like COVID19 infections 症状のある方
※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 | Have symptoms like COVID19 infections. |
| Today's date | Year/Month/Date |
| Faculty Department | Where do you belongs to? |
| ID number | 8 digits of alphabet numbers |
| Are you a Staff or a Student of Chiba-Univ. | Staff/Student |
| Name | Name （pronounciation in hiragana literature if possible） |
| Contacting |
Telephone number E-mail address |
| 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 of appearance: 2022/month/date Symptoms description: |
| Did you had contact with with Chiba-Univ. staffs or students
during these five days? Yes/No |
If yes, please tell us the date, situation and the person's name. Date: year/month/date Situation: Such like went to karaoke, drivings, unmasked conversations or meals Name: |
| Have you went abroad, recently? Yes/No |
If yes, please write when and where have you went. Date: Country Name: |
| Do you belongs to any activities in Chiba-Univ.? Yes/No |
If yes, please tell us 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) |
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 at "@"
Tel: 043-290-2214