BORANG PENGISYTIHARAN DIRI / SELF DECLARATION FORM

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Untuk mengelakkan penyebaran COVID-19 di komuniti kami dan mengurangkan risiko pendedahan kepada pekerja dan pengunjung kami, adalah wajib bagi anda untuk menjawab soal selidik berikut. Terima kasih atas kerjasama anda.

To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our employees and visitors, it is mandatory for you to answer the following questionnaire. Thank you for your cooperation.

1. Nama mengikut Kad Pengenalan atau Pasport / Full Name as per NRIC or Passport *

2. No. Telefon Bimbit / Mobile Number (Sample: 60123456789) *

3. Adakah anda tinggal di kawasan zon merah COVID-19 yang dikemukakan oleh pihak Majlis Keselamatan Negara (MKN)? / Are you staying in any of the COVID-19 red zone stated by the Majlis Keselamatan Negara (MKN)? *

YA / YES (Kalau YA, sila jawab soalan nombor 4. / If YES, please answer question number 4)

BUKAN / NO

Required

4. Zon manakah yang anda tinggal? / Which zone did you stay in?

5. Pernahkah anda mempunyai *kontak rapat dengan pesakit COVID-19 yang disahkan dalam tempoh 14 hari yang lalu? / Have you been in *close contact with a confirmed case of COVID-19 in the past 14 days? *

*Hubungan rapat: Pendedahan berkaitan penjagaan kesihatan, termasuk menyediakan rawatan langsung untuk pesakit COVID-19, yang bekerjadengan pekerja penjagaan kesihatan yang dijangkiti COVID-19, melawat pesakit atau tinggal di tempat yang samapersekitaran pesakit COVID-19. Bekerjasama dalam jarak dekat atau berkongsi persekitaran bilik darjah yang sama dengan pesakit COVID19. Berjalan bersama pesakit COVID-19 dalam apa jua jenis alat pengangkutan. Hidup di rumah yang sama dengan tepuk COVID-19 / *Definition close contact : Health care associated exposure, including providing direct care for COVID-19 patients, working with health care workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient. Working together in close proximity or sharing the same classroom environment with a with COVID19 patient. Traveling together with COVID-19 patient in any kind of conveyance. Living in the same household as a COVID-19 patient.

YA / YES

TIADA / NO

Required

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