Travel Declaration and Contact Tracing Form for Visitors
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
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
Have you been in contact with a confirmed COVID-19 patient in the past 14 days?
Clear selection
Have you been to affected countries/regions in the past 14 days?
Clear selection
Visitor’s full name
Date
MM
/
DD
/
YYYY
Submit
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