Saringan Kesihatan/Health Screening -JOMRENANG ACADEMY-
Answer the questions correctly, honestly and sincerely. #kitajagakita
Email address *
SARINGAN KESIHATAN PELAJAR WAJIB DIHANTAR SEBELUM KELAS RENANG BERMULA
STUDENT HEALTH SCREENING MUST BE SENT BEFORE SWIMMING CLASS STARTS
Nama / Name *
MyKad/MyKid/Pasport *
Umur/Age *
Jantina/Gender *
No Telefon/HP Number *
SARINGAN KESIHATAN UMUM
GENERAL HEALTH SCREENING
Adakah anda mempunyai kurang daya tahan jangkitan atau masalah kesihatan seperti lelah/asma, penyakit kulit sensitif, darah tinggi, kencing manis, penyakit jantung atau penyakit berjangkit? (Nyatakan) Do you have less resistance to infections or health problems such as fatigue / asthma, sensitive skin diseases, high blood pressure, diabetes, heart disease or infectious diseases? (Specify) *
Jika jawapan diatas adalah 'YA' Sila Nayatakan tahap kesihatan semasa anda. / If the answer above is 'YES' Please state your current health level.
SARINGAN SIMPTOM COVID-19 / COVID-19 SYMPTOMS SCREENING
#KITAJAGAKITA
Adakah anda pernah berkunjung atau tinggal diluar negara Malaysia dalam tempoh 14 hari yang lalu? / Have you visited or lived outside Malaysia in the last 14 days? *
Adakah anda pernah menghadiri acara atau mengunjungi mana-mana tempat yang melibatkan kes yang disyaki atau pesakit COVID-19? / Have you ever attended an event or visited any place involving a suspected case or a COVID-19 patient? *
Adakah anda pernah diarahakan untuk menjalani kuarantin disebabkan COVID-19? /Have you ever been directed to quarantine because COVID-19? *
Adakah tempat tinggal atau tempat kerja anda pernah diarahkan untuk menjalani PKPB? / Have a residence or work place you've ever taken through PKPB? *
DO YOU HAVE COVID-19 SYMPTOMS *
YA / YES
TIDAK / NO
BATUK / COUGH
SAKIT TEKAK / SORE THROAT
SELSEMA & BERSIN / COLD & SNEEZING
SUKAR BERNAFAS / HARD TO BREATHE
LAIN-LAIN (NYATAKAN DI BAWAH) / OTHERS (STATE BELOW)
NYATAKAN SIMPTOM LAIN JIKA ADA / STATE OTHER SYMPTOMS IF ANY
PERAKUAN/ AGGREMENT APPROVAL #KITAJAGAKITA *
TARIKH SERAHAN/SUBMISSION DATE *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy