Health Declaration Form
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.
Email *
Name: *
Address *
Mobile No *
Email address *
NRIC/ Passport No
1. Have you travelled abroad (i.e. to any countries outside of Singapore) in the past 14 days? *
2. Do you have flu-like symptoms (e.g. fever, cough, runny nose, sore throat, 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? *
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. 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? *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy