Health & Travel Declaration Form

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Dear Sir/Madam,
To prevent the spread of COVID-19 virus in our community and reduce the risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in the building as well as for use during contact-tracing. Thank you for your time.
Name*
Personal Contact Number*
Purpose of Visit*
- Trainer
- Trainee
- Meeting
- Enquiry
- Others
1. Do you have the following symptom(s) such as fever (37.5 degrees and above), cough, sore throat, runny nose?*
- Yes
- No
2. Have you or your family member been in contact with a confirmed COVID-19 patient in the past 14 days?*
- Yes
- No
3. Have you been to the following places in the past 14 days?*
- Yes
- No
1. Mainland China, Iran, South Korea,

2. Or the following countries from 15 Mar 2020? Italy Germany France Spain

3. Or the following countries from 17 Mar 2020? Switzerland United Kingdom Japan ASEAN Countries including Malaysia (e.g. JB) and Indonesia (e.g. Batam/Bintan)
Please provide further details on your travel history:*
I confirm that the above information is correct and accurate. I also understand that omitting or providing false information is an offence under the Infectious Disease Act.
Date of Visit:
03/12/2024
Signature

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