Health Screening / Declaration Form

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Health Screening/Declaration for Attending Mass in Church/Chapel in
Penampang Parish During Recovery Movement Control Order

Please kindly take the health screening test before leaving home for Mass. Thank you.

Name *

Tel No *

Please answer the following truthfully Yes/No.

Do you require a helper or carer to assist you in church because you are unable to ambulate or walk or care on your own without help from others? *

Yes

Have you travelled to other countries or been in *close contact with anyone who has travelled to Red zone area for Covid-19 within the last 14 days? *

Yes

Do you currently have either cold or flu or cough or fever (temperature 37.5 celcius and above) or some difficulty of breathing? *

Yes

Do you have illness or conditions of the following: #Chronic or uncontrolled diabetes, chronic# hypertension, diagnosed with cancer not recover yet, diseases or conditions that can resulted in immune-suppression e.g. AIDS, receiving treatment chemotherapy or haemodialysis or radiotherapy or on strict doctors’ follow up, just discharged from hospital? *

Yes

Have you had *close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *

Yes

Are you age 12 and below or age 70 and above? *

Yes

* Close contact means either living with the positive Covid-19 person in same house or in contact within confined space/ room/office with at least 15 minutes duration

* Chronic means having been diagnosed for a disease/condition continuously for many years

If you have answered ‘Yes’ to any of the questions above, you are not allowed to attend mass in person in the church or chapel or big gathering. You are advised to seek medical help or treatment. Please review the questions weekly when deciding to apply to attend mass during the RMCO period.

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