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COVID-19 HEALTH DECLARATION FORM
Kindly complete the following form to facilitate contact tracing, if necessary.
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Email
*
Your email
Name
*
Your answer
NRIC (last 3 digits and checksum)
*
Your answer
Phone number
*
Your answer
Project Name / location
*
Your answer
Temperature at Time of Form Submission - Degree Celsius (℃)
*
Your answer
DECLARATION
Have you travelled to Covid-19 affected countries in the last 14 days?
*
Yes
No
Required
Have you been in contact with anyone who is suspected to have or/has been diagnosed with Covid-19 within the last 14 days?
*
Yes
No
Required
Do you have any of the following symptoms now or within the last 14 days: Cough, smell/taste impairment, fever, breathing difficulties, body aches, headaches, fatigue, sore throat, diarrhoea, and / or runny nose (even if your symptoms are mild)?
*
Yes
No
Required
I hereby declare that I have answered the above questions truthfully
By providing personal data through this declaration form, you authorise Mods360 to collect, use, process and disclose personal data provided for the purpose of verifying your identity, screening your health status and maintaining records for contact tracing purposes, to ensure our safety and security. The information collated here will be securely discarded once there are no business and legal purposes to keep them.
A copy of your responses will be emailed to the address you provided.
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