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Infection Report (Except for COVID-19)

This form is to inform the Institute that you have been infected with an infectious disease other than COVID-19.

・Fill in all the fields marked with an asterisk (*).

・Click "Resume later" button in the upper right corner of the screen to temporarily save the form.

For any inquiries, contact nurses@jim.titech.ac.jp

There are 21 questions in this survey.