DECLARATION FORM

Date

Institution I intend to go to

I am

Patient Name

Please provide your particulars

Your Name

Your NRIC / FIN / Passport

Mobile No

Email

I am going to

Location Others

Declaration by Patient/Visitor

1.Do you have flu-like symptoms (e.g. fever, cough, runny nose, sore throat or loss of taste / smell, etc.)?

OR

Have you tested ART positive in the past 72 hours?

Yes
No

2. Are you currently serving Stay-Home Notice (SHN)?

Yes
No

3. Are you currently under MOH Health Risk Warning (HRW) / Health Risk Notice (HRN) monitoring?

Yes
No

The information you provide is important in managing the risk of COVID-19 transmission. The Infectious Diseases Act requires a person who has reason to suspect that he is a case or carrier of COVID-19, or has had contact with a person with COVID-19, to act in a responsible manner to not expose other persons to the risk of infection by the disease.

DECLARATION FORM​​​

Please provide your particulars

Declaration by Patient/Visitor

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DECLARATION FORM