For those who are infected with COVID19. 陽性者の方へ
※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 | Infected with COVID19 |
| Today's date | Year/Month/Date |
| Faculty Department | Where you belongs |
| 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 Where you live（city and town name） |
| Last entering date of Chiba-Univ. | year/month/date |
| Do you have any symptoms? Yes/No | If Yes, please tell us the date and description of your symptoms. Date of appearance: 2022/month/date Symptoms in details please: |
| Have you went abroad, recently? Yes/No |
If yes, please write when and where you went. Date: Country Name: |
| Have you taken medical consultation? Yes/No |
If yes, please tell us the date and the medical institution name. Consutation date: Medical institution Name: |
| Antigen testing | Done/ Not done Result（ ）Testing date(year/month/date) |
| PCR testing | Done/ Not done Result（ ）Testing date(year/month/date) |
| COVID19 confirmed date. | 2022/month/date |
| Did you had 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: |
| If the person with COVID19 infection is Chiba-Univ.'s staff or students, please tell us who. | Name ※It relates for the public absences. |
| Behavioral history from 2 days prior to onset date to present (as detailed as possible). | ※If you had attendant in Chiba-Univ., please list the name of the lecture, instructor, class format (face to face or group work), etc. |
| Did you had any unmasked conversations or meals with Chiba-Univ. staffs or students? Yes/No |
If yes, please tell us the person's name. 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: |
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, and 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