Health Declaration Form
The information is being collected as part of the response to the outbreak of the COVID-19 and will be
used by the Company for that purpose. This is part of our preventive measures to mitigate the risk of
COVID-19 and at the same time, ensure the safety of all our employees and family members.
Company : __________________________ Position : _______________________
Employee
: __________________________ Contact No. : _______________________
Name
Health Information (Please tick (✓) in the appropriate space)
1. Have you or your family members experienced any of the following symptoms in the past 14
days?
SYMPTOMS YES NO
Fever
Cough
Running Nose
Difficulty Breathing
Sore Throat
Diarrhoea
Loss of Taste/ Smell
Muscle Ache
Others Symptom: (please state)
Any Recent or Current Illness
(I.e. dengue, Influenza, etc.).
Kindly specify.
2. Have you had any close contact with patients or suspects or recent cluster announced by
Ministry of Health (MOH) suffering from COVID-19 in the past 14 days?
Yes No
3. Is there anyone in your household/ residential area/ premises/ building with confirmed COVID-
19 positive in the past 14 days?
Yes No
4. Is there anyone in your household/ residential area/ premises/ building suspected of COVID-
19 positive or under investigation (PUI) or under recent cluster announced by MOH?
Yes No
5. Have you travelled overseas for the past 30 days? If yes, please state the Country name.
Yes No Country Name: _______________________
6. Have you travelled or been to location that being affected by recent clusters announced by
MOH of COVID-19 for the past 30 days? If yes, please state the location.
Yes No Location: ____________________________
DECLARATION AND CONSENT
I hereby declare that the information given above is true and accurate and if the information given is
false, discipline action can be taken against me.
I agree and understand that the Company or the local health agencies may decline my entry into the
office premises, quarantine, isolate or place me under surveillance if there is a reasonable belief that I
am infected with or has been exposed to the COVID-19 virus.
I, the undersigned hereby agree, consent and authorize by the Company to collect, use, process, and
store my personal data, and/ or sensitive personal data as stated in this form to the local health agencies,
third party and/ or in the manner outlined in the form in the interest of public health.
_____________________________ ________________
(Signature) (Date)
Name:
NRIC:
