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2015. Osong Public Health Res Perspect 2015;6(4):269-278.

Alsahafi AJ et al The epidemiology of Middle East respiratory syndrome coronavirus in the

Kingdom of Saudi Arabia, 20122015. International Journal of Infectious Diseases 2016;45:14.

Assiri A. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med

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13) NIOSH : National Institute for Occupational Safety and Health

14) EU-OSHA : European Agency for Safety and Health at Work15) :

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()H EALTH Q U ES TIO N NAIR E

()Name

() Arrival Date(YY/MM/DD)

() Nationality

()VesselFlightTrainCar No.

() Passport No.

() Seat No.

()Birth Date(YY/MM/DD)

( )Last seven digits of ID. No (Write for Only Korean)

()

Sex [ ]()Male [ ]()Female

() ()Mobile Phone No.(Tel.)

() Contact address in Korea

14 . .

Please list the countries where you have stayed during the past 14 days before arrival.

1) 2) 3)

14 .

.

Please check a mark, if you have or have had any of the following symptoms during the past 14 days

before arrival.

[ ] (,)

Runny or stuffy nose

[ ]()

Sore throat

[ ]()

Cough

[ ]()

Fever

[ ]()

Diarrhea

[ ]()

Vomiting

[ ]()

Abdominal pain

[ ]()

Difficulty breathing

[ ] ()

Shortness of breath

12 39 1 1 .

.

If you make a false statement concerning your health or fail to fill out the Health Questionnaire, you may face a sentence of up to one year of imprisonment or up to 10 million won in fines, in accordance with Articles 12 and 39 of the Quarantine Act.

National Quarantine Officer Ministry of Health and Welfare

Republic of Korea

- 103 -

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Name Date of Birth

Self-Quarantine

Duration effective today until

Place

[ ] Residence(including home)

[ ] Other facility

Address

Notice of Self-Quarantine

The government of the Republic of Korea notify you that you must be

self-quarantined for requested period of time according to Infectious

Disease Control and Prevention Act, Article 41.3.2

If you do not comply with this notice, you will be fined up to 3

million-won based on Infectious Diesease Control and Prevention Act,

Article 50.2

Year Month Date

MayorGovernor of metropolitan cities and provinces or

MayorGovernorHead of district office[gu], Head of

medical institution

- 111 -

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599(119/480) 40 31 (79) 15 114 (465)

- 119 -

361-951 2 187

Tel : 043) 719-7788, 7787, 7785

Tel : 043) 719-7789, 7790

Tel : 043) 719-7954, 7976, 7675

Tel : 043) 719-7253, 7252

Tel : 043) 719-7141, 7144

Tel : 043) 719-7162, 7165

Tel : 043) 719-7845, 7849

Tel : 043) 719-8210, 8222

Tel : 043) 719-8045, 8041