Saringan Kesihatan/Health Screening -JOMRENANG ACADEMY-

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Answer the questions correctly, honestly and sincerely. #kitajagakita

Email *

SARINGAN KESIHATAN PELAJAR WAJIB DIHANTAR SEBELUM KELAS RENANG BERMULA

STUDENT HEALTH SCREENING MUST BE SENT BEFORE SWIMMING CLASS STARTS

Nama / Name *

MyKad/MyKid/Pasport *

Umur/Age *

Jantina/Gender *

Lelaki/Male

Perempuan/Female

No Telefon/HP Number *

SARINGAN KESIHATAN UMUM

GENERAL HEALTH SCREENING

Adakah anda mempunyai kurang daya tahan jangkitan atau masalah kesihatan seperti lelah/asma, penyakit kulit sensitif, darah tinggi, kencing manis, penyakit jantung atau penyakit berjangkit? (Nyatakan) Do you have less resistance to infections or health problems such as fatigue / asthma, sensitive skin diseases, high blood pressure, diabetes, heart disease or infectious diseases? (Specify) *

YA / YES

TIDAK / NO

Jika jawapan diatas adalah 'YA' Sila Nayatakan tahap kesihatan semasa anda. / If the answer above is 'YES' Please state your current health level.

SARINGAN SIMPTOM COVID-19 / COVID-19 SYMPTOMS SCREENING

#KITAJAGAKITA

Adakah anda pernah berkunjung atau tinggal diluar negara Malaysia dalam tempoh 14 hari yang lalu? / Have you visited or lived outside Malaysia in the last 14 days? *

YA/YES

TIDAK/NO

Adakah anda pernah menghadiri acara atau mengunjungi mana-mana tempat yang melibatkan kes yang disyaki atau pesakit COVID-19? / Have you ever attended an event or visited any place involving a suspected case or a COVID-19 patient? *

YA/YES

TIDAK/NO

MUNGKIN/MIGHT BE

Adakah anda pernah diarahakan untuk menjalani kuarantin disebabkan COVID-19? /Have you ever been directed to quarantine because COVID-19? *

YA/YES

TIDAK/NO

Adakah tempat tinggal atau tempat kerja anda pernah diarahkan untuk menjalani PKPB? / Have a residence or work place you've ever taken through PKPB? *

YA/YES

TIDAK/NO

Other:

DO YOU HAVE COVID-19 SYMPTOMS *

YA / YES

TIDAK / NO

BATUK / COUGH

SAKIT TEKAK / SORE THROAT

SELSEMA & BERSIN / COLD & SNEEZING

SUKAR BERNAFAS / HARD TO BREATHE

LAIN-LAIN (NYATAKAN DI BAWAH) / OTHERS (STATE BELOW)

NYATAKAN SIMPTOM LAIN JIKA ADA / STATE OTHER SYMPTOMS IF ANY

PERAKUAN/ AGGREMENT APPROVAL #KITAJAGAKITA *

Dengan ini saya mengesahkan bahawa segala maklumat yang dinyatakan di atas adalah BENAR dan saya BERSETUJU dengan semua syarat yang ditetapkan oleh Jomrenang Academy dan Pihak Pengurusan Kolam Renang.

I hereby confirm that all the information stated above is TRUE and I AGREE to all the conditions set by Jomrenang Academy and Swim Pool Management.

TARIKH SERAHAN/SUBMISSION DATE *

YYYY

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

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