健康申报表 SCREENING QUESTIONNAIRE (HEALTH DECLARATION)
请在出席崇拜/团契/小组当天提交。 Please submit the form on the day/s that you are attending service/fellowship/cell group
电邮地址 email address
Your answer
姓名 Name *
Your answer
联络号码 Contact number *
Your answer
今天的日期 Today's date *
MM
/
DD
/
YYYY
出席崇拜/团契/小组 *
Attending service/fellowship/cell group
Required
过去14天内是否有离开新加坡,到别的国家去?Have you travelled anywhere out of Singapore in the last 14 days? *
请回答以下的问题 *
Please answer the questions below
有 Yes
没有 No
你是否有跟COVID-19确诊者或疑似病近距离相处?Have you been in close contact with someonewho is a suspected or confirmed case of COVID-19
你是否跟履行缺席假/居家通知的人同住?Are you living in the same house as someone on Home Quarantine Orders or Stay Home Notice?
你是否正在履行缺席假/居家通知期间? Are you currently serving a Stay-Home Notice, or are you on a Leave of Absence from work?
在过去14天内,你是否接触过任何本地的感染 集群? Have you been in any of the known local clusters in the last 14 days?
你是否在过去一周有高烧或者以下症状(咳嗽,喉咙痛,流鼻涕,呼吸困难等) Do you have any fever or respiratory symptoms in the last 1 week (cough, sore throat, runny nose, breathlessness)
如果您对以上任何问题中有一个回答“是”,请你务必去看医生然后留在家中休息
Please see a doctor and rest at home if your answer "Yes" to any of the questions
备注 Note
根据个人保护资料法令,提供以上资料表示您同意让教会内部使用所提供的资料。您提供的资料将被保密。

By providing the above information, you consent to Geylang Chinese Methodist Church collecting and using the data for internal usage in accordance with the Personal Data Protection Act. All information provided by you are treated with strictest confidentiality.
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