Covid-19 Seft-Declaration Form

Due to the ongoing and rapidly changing situation with the novel-coronavirus (COVID-19), we are
requiring all worker for Centoz One Puchong to fill-out the self-declaration form below.Main Contractor
Prefabtech will make a decision on access to the site based on the answers provided below.

Oleh kerana situasi yang sedang berlaku dengan cepat dengan novel-coronavirus(COVID-19), kami
meminta smua pekerja untun projek Centroz One Punchong untuk mengisi borang pengisytiharan diri di
bawah. Kontraktor Utama (Prefabtech) akan membuat keputusan mengenai akses ke tapak pembinaan
berdasarkan jawapan yang diberikan di bawah.

Each staff,workers and visitor must complete this form

Setiap kakitangan, pekerja dan pelawat mesti mengisi borang ini

Name :
Address :
Nationality :
Tred/ Company
Supervisor Name :
Health History* :
*chronic diseases need to be declared to help authorities if effection cases happen.

1. Do you have any of the following flu-like systoms:

Adakah anda mempunyai systom seperti selsema berikut:

Fever (38° or higher) Yes No

Cough Yes No
Breathlessness Yes No
Sore throat Yes No
Other: Please specify Yes No

Covid-19 Seft-Declaration Form

2. Please list the country/cities you have travelled to in the 14 days.
Sila senaraikan negara/bandar yang pernah anda kunjungi dalam 14 hari terakhir.

Name of Country/City
Date of arrival
Date of departure
Transit city
Transit date

3. Have you ir an immediate member come in close contact with a comfirmed case of the coronavirus in
the last 14 days? (“Close contract” mean being at a distance of less than one metre for more than 15
minutes.)

Pernahkah anda atau ahli keluarga terdekat mempunyai kontak rapat dengan kes coronavirus yang
disahkan dalam 14 hari terakhir?(“kontak rapat”bermaksud berada pada jarak kurang dari satu meter
selama lebih dari 15 minit.)

I have been in close contact with a cinfirmed case of coronavirus in Yes No

the last 14 days.

This document will be retained confidentially by the main contractor for one month after submission. The
health and wellbeing of our staff/workers is our first priority therefore main contractor (Prefabtech)
reserves the right to deny entry to the contruction site.

Signature : ______________________________

Date : ______________________________