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DECLARATION FORM

Institution I intend to go to
I am

Please provide your particulars

Name
NRIC / FIN / Passport
Mobile No
I am going to
Date

Declaration by Patient/Visitor

1. Have you, in the past 14 days, returned from:
  • China
  • Daegu City or Cheongdo County, South Korea?

2. Do you have flu-like symptoms (e.g. fever, cough etc.)?

3. Did you, in the past 14 days, come in close contact with someone who
(i) Is a confirmed COVID-19 case; OR
(ii) Is part of a COVID-19 cluster; OR
(iii) Had been in:
  • China
  • Daegu City or Cheongdo County, South Korea?

4. Have you returned from the Middle East* in the past 14 days?
*High Risk Middle Eastern Countries (for MERS-CoV) include: Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates & Yemen

5. Do you have flu-like symptoms (e.g. fever, cough etc.)?

6. Did you come in contact with someone who has returned from Middle East and he/she is not feeling well in the past 14 days?

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.

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