Covid-19 Declaration Form

Time*

: Hour

Minute

Choose Your Kindergarten*

Name*

Phone Number*

NRIC/Passport No.*

Location*

Temperature Reading*

Recorded by...*

You are from...*

SELF-DECLARATION

Do you have the following symptom(s)?

Select All
Fever (demam)
Cough (batuk)
Sore throat (sakit tekak)
Shortness of breath (sesak nafas)
Other (lain-lain)
Non Above

If other, please state here..*

Have you been in contact with any Covid-19 cluster declared by MOH or Person Under Investigation (PUI) or a confirmed Covid-19 patient in the past 14 days?*

Yes
No

Have you been to affected Covid-19 countries or area(s) in the past 14 days?*

Yes
No

If yes, please indicate the affected country(s) or area(s)

Covid-19 Declaration Form

Health Screening Form

SELF-DECLARATION