Travel Declaration and Contact Tracing Form for Visitors

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Dear Sir / Madam

To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this premise. Thank you for your time.

Visitor’s full name

Personal Contact Number (Mobile number/Home)

NIRC/Passport Number (last 4 digits)

Nationality

Venue of visit

Bubbly Petz

Hey Good Cat

Clear selection

Temperature reading of visitor

Recorded by staff (name)

Self Declaration by Visitor

If you have the following symptom(s), please check the following boxes

Fever

Dry cough

Body aches

Headaches

Sore throat

Runny nose

Tiredness

Shortness of breath

Other:

Have you been in contact with a confirmed COVID-19 patient in the past 14 days?

Yes

Clear selection

Have you been to affected countries/regions in the past 14 days?

Yes

If yes, please indicate the affected countries/regions

Clear selection

Visitor’s full name

Date

YYYY

Submit

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