Health Declaration Form

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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.

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? *

Yes

2. Do you have flu-like symptoms (e.g. fever, cough, runny nose, sore throat, etc.)? *

Yes

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? *

Yes

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 *

Yes

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? *

Yes

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