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Registration form for Chiang Mai University’s staff and students who have been in a COVID-19 risk area or have been in contact with someone who tested positive for COVID-19
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* Indicates required question
Name-Surname
*
Your answer
Student ID (If you are an employee, please specify your position)
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Your answer
Faculty/Division/Center/Institute
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Your answer
Mobile phone number
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Your answer
Emergency contact number (parent/relative)
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Your answer
Do you have any of these symptoms ?
*
Fever
Runny nose
Cough
Shortness of breath
Sore throat
Diarrhea
Anosmia (loss of smell)
Ageusia (loss of taste)
No symptoms
Other:
Required
Do you have a medical condition?
*
None
Yes (please specify in the "other" box below)
Other:
Travel history report of 55th COVID-19 confirmed case in Chiang Mai
Travel history report of 56th COVID-19 confirmed case in Chiang Mai
Travel history report of 58th COVID-19 confirmed case in Chiang Mai
Travel history report of 61st COVID-19 confirmed case in Chiang Mai
Travel history report of 62nd COVID-19 confirmed case in Chiang Mai
Travel history report of 63rd COVID-19 confirmed case in Chiang Mai
Travel history report of 66th COVID-19 confirmed case in Chiang Mai
The area you traveled to (Please specify the place, date, and time in detail)
*
Your answer
Have you been tested for COVID-19?
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No
Yes (please specify the day-month-year of the exam in the "other" box below)
Other:
Address in Chiang Mai Province:
*
Your answer
Please describe your current accommodation situation. Do you live in a private or shared room/apartment with a bathroom? Does the property have elderly residents or residents with hereditary diseases? Are you currently self-isolating?
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Your answer
Have you registered in the CMU SELF CHECK FOR COVID-19 yet? (Where you are asked to provide your daily health report for 14 days)
*
Registered
Not registered yet
QR Code to register for health assessment in CMU SELF HEALTH CHECK FOR COVID-19 (if the questions are only in Thai, please use Google to auto-translate).
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