个人健康情况声明Health Status Statement

请考生仔细填写，谢谢合作
Please fill out the questionare and sign this statement. Thank you.

*2.

本人目前身体状况 Health Status

*3.

您的共同居住人是否有发热、咳嗽、乏力、呼吸困难等症状 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天内是否接触过确诊、疑似或已被隔离人员 本人及共同居住人14天内是否接触过近期境外回国人员 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天内是否接触过近期境外回国人员 Have you and your co-residents had direct contact with recent returnee(s) from overseas?

*7.

考试日期 Administration Date 

（请按照 年、月、日的顺序填写）(mm/dd/yy)

*9.

紧急联系人电话 Emergency Contact

不得与本人电话相同，一旦出现特殊情况，必要时考点将与紧急联系人取得联系 Please leave a different number from your phone number, just in case we need to contact this person in any emergency.

*10.

以上内容为本人认真填写，如存在隐瞒事实情况，由此产生的一切后果及遭受的经济损失均由本人独自承担，与考点没有任何关系。
The above content is carefully filled in, if there is any concealment, I will personally bear all the consequences.

一旦参加考试，本人在考试期间或考后发生异常情况，而经考点核实属于考前即存在未愈的病情情况，责任由本人承担。
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. 

承诺人：
Committed by:

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