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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.
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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 -
2.
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[ ] [ ] [ ] [ ]
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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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(MERS)
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3 23(5/18) 5 - 28
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19(3/16) 3 - - 4(4*4)
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6 25(5/20) 12
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7 25(5/20) 12
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8 25(5/20) 12
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9 35(10/25) 23
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10 35(5/30) 12
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11 26(5/21) 11
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19 24(4/20) 21
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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