Permission of Return to Campus(faculty and staff members)
Belong to institution other than affiliated schools

For university faculty and staff members(not including university faculty and staff members who belong to Shinanomachi campus)
Name ：
ID Number：① What to do if you miss class due to contracting influenza (excluding avian influenza H5N1) or COVID-19
Please return to campus once your fever has subsided naturally (without the help of medication) and you meet the other criteria for coming to school.
On your first day back, please bring this certificate with the bolded section filled out, along with one of the following items as proof that you weresick, to the Keio University Health Center and speak with staff about your condition. If you have COVID-19, please wear a mask for 10 days after
the onset of symptoms.
Acceptable proof of illness-The results of tests performed at medical institutions and laboratories (documents or printed photos listing your name, typeof test, results, and name of the medical institution or laboratory).
-The results of the self-administered rapid antigen test kit (documents or printed photos that shows the test kit's product name, manufacturer, anddistributor, as well as the test results (control and test lines)).
-An instruction sheet for an antiviral drug or medicine packaging that displays the date it was prescribed, and your name written on it.
-A certificate of diagnosis issued by the health care center you visited.
Infectious diseases

The criteria for return to work

Influenza(excluding Avian Influenza)

More than 48 hours after you no longer have a fever without the use of fever-Meet the criteria?
YesNo

reducing medicines.
COVID-19(coronavirus disease)5 days after the onset of symptoms (on the 6th day of illness) and 1 day since yoursymptoms have subsided (on the 2nd day after symptoms has subsided).

※The day of onset and the day of fever subsided are counted as day 0.

(Please circle the appropriate box.)② If having the suspected or confirmed infectious diseases which are listed below,
Please ask a doctor to fill out the double line-frame box and on the first day of return to work, submit this certificate to the Health Center.
Because of the following infectious disease, the measures described below should be considered for the above faculty or staff.
(上記の者は、下記の疾病の感染性を考慮し、就業について以下の措置が望ましいと判断します。)
Infectious diseases(感染症）
Tuberculosis（結核）Measles（麻疹）Epidemic parotitis(Mumps)（流行性耳下腺炎）

Pharyngoconjunctival fever/Epidemic keratoconjunctivitis, etc.
（咽頭結膜熱・流行性角結膜炎等）

Rubella（風疹）Infectious enteritis（感染性腸炎）＊（Varicella(chickenpox)（水痘）

Other infectious diseases（その他）（Date of the first visit (初診) :The first day to return to campus (就業許可):）(Please circle the appropriate box.)

mm(月)/ dd(日)/ yyyy(年)Period of exclusion from campus (就業禁止期間):）

mm(月)/ dd(日)/ yyyy(年)～ mm(月)/ dd(日)/ yyyy(年)mm(月)/ dd(日)/ yyyy(年)Name of medical institution (医療機関名):
Name of doctor (医師名):

stamp (捺印),Issued date (発行日):

mm(月)/ dd(日)/ yyyy(年)* Infectious gastroenteritis (Viral gastroenteritis) ( 感 染 性 胃 腸 炎 ( ウ イ ル ス 性 胃 腸 炎 )), Cholera ( コ レ ラ ), Shigellosis ( 細 菌 性 赤 痢 ),Enterohemorrhagic E. coli infection (腸管出血性大腸菌感染症), Typhoid fever (腸チフス), paratyphoid fever (パラチフス)…

所属長

人事課長

人事部長

登校禁止期間登校許可
保健管理センター確認日

20年

月日午前・午後から20

年

月日午前・午後20２０年
年

月月日
日 （体温℃）

Your information is never disclosed or provided to a third party without your prior consent, except when required by Japanese law. Personal medical information andpersonal information will be treated appropriately and in accordance with the Keio University Rules for Protection of Personal Medical Information (keio gijuku iryokojinjoho hogokitei), the Keio University Rules to Protect Personal Information (keio gijuku kojinjoho hogokitei) and the Keio University Regulations Concerning theProtection of Personal Information in Academic Research (keio gijuku no gakujitsukenkyu no yo ni kyosuru kojinjoho hogokitei). Please note that the rules andregulations listed above are only available in Japanese. See Keio University's English privacy policy page for details: https://www.keio.ac.jp/en/privacy-policy/
20240401