DECLARATION FORM

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DECLARATION FORM

The information you provide is important in managing the risk of COVID-19 transmission. The Infectious Diseases Act requires a person who has reason to suspect that he is a case or carrier of COVID-19, or has had contact with a person with COVID-19, to act in a responsible manner to not expose other persons to the risk of infection by the disease.

Email *

Name *

Mobile Number *

Date of Visit *

YYYY

Time of Visit *

Time

Temperature Reading: Above / Below 37.5C (please indicate your temperature reading) *

Have you returned from China, Republic of Korea, Japan, Italy, Iran, France, Spain, Germany, Switzerland, United Kingdom, and ASEAN countries* in the past 14 days? *ASEAN Countries besides Singapore: Brunei Darussalam, Cambodia, Indonesia, Lao PDR, Malaysia, Myanmar, Philippines, Thailand, Vietnam *

Yes

2. Do you have flu-like symptoms (e.g. fever, cough etc.)? *

Yes

3. Did you, in the past 14 days, come in close contact with someone who(i) Is a confirmed COVID-19 case; OR(ii) Is part of a COVID-19 cluster? *

Yes

4. Have you returned from the Middle East* in the past 14 days? *High Risk Middle Eastern Countries (for MERS-CoV) include: Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates & Yemen *

Yes

5. Did you come in contact with someone who has returned from Middle East and he/she is not feeling well in the past 14 days? *

Yes

A copy of your responses will be emailed to the address you provided.

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