請(qǐng)考生仔細(xì)填寫(xiě)，謝謝合作
Please fill out the questionare and sign this statement. Thank you.

*2.

本人目前身體狀況 Health Status

*3.

您的共同居住人是否有發(fā)熱、咳嗽、乏力、呼吸困難等癥狀 Do(es) your co-resident(s) have symptoms such as fever, cough, fatigue, and difficulty in breath?

*4.

本人及共同居住人14天內(nèi)是否接觸過(guò)確診、疑似或已被隔離人員 本人及共同居住人14天內(nèi)是否接觸過(guò)近期境外回國(guó)人員 Have you and your co-resident(s) had direct contact with confirmed, suspected or quarantined person within 14 days?

*5.

本人及共同居住人14天內(nèi)是否接觸過(guò)近期境外回國(guó)人員 Have you and your co-residents had direct contact with recent returnee(s) from overseas?

*7.

考試日期 Administration Date 

（請(qǐng)按照 年、月、日的順序填寫(xiě)）(mm/dd/yy)

*9.

緊急聯(lián)系人電話 Emergency Contact

不得與本人電話相同，一旦出現(xiàn)特殊情況，必要時(shí)考點(diǎn)將與緊急聯(lián)系人取得聯(lián)系 Please leave a different number from your phone number, just in case we need to contact this person in any emergency.

*10.

以上內(nèi)容為本人認(rèn)真填寫(xiě)，如存在隱瞞事實(shí)情況，由此產(chǎn)生的一切后果及遭受的經(jīng)濟(jì)損失均由本人獨(dú)自承擔(dān)，與考點(diǎn)沒(méi)有任何關(guān)系。
The above content is carefully filled in, if there is any concealment, I will personally bear all the consequences.

一旦參加考試，本人在考試期間或考后發(fā)生異常情況，而經(jīng)考點(diǎn)核實(shí)屬于考前即存在未愈的病情情況，責(zé)任由本人承擔(dān)。
Once I take the test, if any abnormal situation on me during and after the test had been verified by the test center to be unhealed condition, I will personally bear all the consequences. 

承諾人：
Committed by:

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