Visitor Declaration Form
I Can Write Too Tuition Centre Pte Ltd
Name *
2. Contact Number / Parent's Contact Number *
3. Purpose of Visit (Please indicate as appropriate) *
If Others, please specify purpose of visit:
4a.Date of Visit *
4b.Time of Visit *
Time
:
5.Are you feeling unwell or have symptoms (such as fever, running nose, sore throat, cough, muscle ache, shortness of breath,change in smell, diarrhoea)? *
6.Within the last 14 days, have you been in contact with a member of your household who is unwell (have symptoms as stated above)? *
7.Within the last 14 days, have you had contact with a COVID-19 confirmed case or suspect case, or a person issued Quarantine Order (QO) / Leave of Absence (LOA) / Stay-Home Notice (SHN)? *
8.Are you currently serving Quarantine Order (QO) / Leave of Absence (LOA) / Stay-Home Notice (SHN)? *
If your answer for any of Questions 5 to 8 above is "Yes", please do not enter the centre and seek medical assistance if feeling unwell. If you are currently serving QO /LOA/SHN, please return home immediately. Thank you for your kind understanding.
Acknowldegement : By submitting this form, I understand that my personal data is protected and the data gathered is used only for contact tracing should the need arise. *
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