BORANG COVID-19 SCREENING OF

KEMENTERIAN UTILITI SARAWAK EMPLOYEES OF MINISTRY OF UTILITIES

SARAWAK
No. Dokumen : Tarikh Berkuatkuasa :
No. Pindaan 01
B 4108 28 Julai 2020

No. Keluaran : 01 Muka Surat 1/4

COVID-19 SCREENING OF EMPLOYEES OF MINISTRY OF UTILITIES SARAWAK

As part of safety precautions to keep our workplace and employees safe, we will do the screening for
COVID-19 symptoms and risk factors at EACH WEEK.

Kindly complete your personal information and simple questionnaire as below. Thank you for your
cooperation.

Name : Maria Lunsa

Department/ Unit/Section : Pejabat YB Menteri Utiliti

Level : 10

Hand phone Number : 0198657578

Home Address : lot 142D, Taman Sri Perkasa, Lorong Sri Perkasa 4A, Jalan Matang,
Kuching

1. Have you returned from any infected Country/State or Infected Local Area within the last 14 days?
No

Yes. Please Specify and forward all related documents together with this form to Officer in-
Charge.

Name of the infected Country/ :

State or Infected Local Area

Date of Quarantine Order: :

Date of Quarantine Release Order: :

2. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last
14 days?
No

Yes. Please Specify and forward all relevant documents together with this form to Officer in-
Charge.

Name:
Relationship:
Date of Quarantine Order:
Date of Quarantine Release Order:

3. Have you or any of your household members been quarantined within the last 14 days or is / are
currently still in quarantine?
No

Yes. Please Specify and forward all relevant documents together with this form to Officer in-
Charge.
 BORANG COVID-19 SCREENING OF
KEMENTERIAN UTILITI SARAWAK EMPLOYEES OF MINISTRY OF UTILITIES
SARAWAK
No. Dokumen : Tarikh Berkuatkuasa :
No. Pindaan 01
B 4108 28 Julai 2020

No. Keluaran : 01 Muka Surat 2/4

Name of officer’s / household’s member:

Relationship:
Date of Quarantine Order:
Date of Quarantine Release Order:

4. Does any of your household members working as a front liner?

No

Yes. Please specify:

Name :
Relationship :
Department/Agency:
Position :

5. Have you been in or identified as close contact with anyone who has travelled within the last 14 days
to any infected Countries / State or Infected Local Area?
No

Yes. Please specify and forward all relevant documents together with this form to Officer in-
Charge.

Name of Officer / Closed Contact:

Relationship:
Date of Quarantine Order:
Date of Quarantine Release Order:

6. Have you been quarantined or are you in quarantine as a result of having close contact with persons
mentioned in items 2, 3, 4 and 5?
No

Yes. Please Specify and forward all relevant documents together with this form to Officer in-
Charge.

Date of Quarantine Order: :

Date of Quarantine Release Order: :

7. Have you experienced any cold or flu-like symptoms in the last 14 days includes cough, sore throat,
respiratory illness, difficulty breathing, had body temperature that is elevated or above 37.3° C?

No

Yes. Please STAY AT HOME or/and WORK FROM HOME and/or CONSULT any Medical Practioner.
 BORANG COVID-19 SCREENING OF
KEMENTERIAN UTILITI SARAWAK EMPLOYEES OF MINISTRY OF UTILITIES
SARAWAK
No. Dokumen : Tarikh Berkuatkuasa :
No. Pindaan 01
B 4108 28 Julai 2020

No. Keluaran : 01 Muka Surat 3/4

Please submit the completed form and related documents (if necessary) to Miss Norma anak Peterin via
email at normap@sarawak.gov.my or whatsapp on or before FRIDAY of each week for record and
monitoring. If the answer is “YES” to any of the questions, access to the Ministry’s office is denied. Please
NOTE for answer “YES” to question no. 2 & 3, all information and related documents will be submitted to
relevant authorities for follow-up instructions / action. Please refer to the Attachment 1 for Declaration
Renewal.

Employee Signature: Date: 18.09.2020

 BORANG COVID-19 SCREENING OF
KEMENTERIAN UTILITI SARAWAK EMPLOYEES OF MINISTRY OF UTILITIES
SARAWAK
No. Dokumen : Tarikh Berkuatkuasa :
No. Pindaan 01
B 4108 28 Julai 2020

No. Keluaran : 01 Muka Surat 4/4

Attachment 1

DECLARATION RENEWAL FORM

If there is NO CHANGE in the INFORMATION PROVIDED just fill in the new declaration date in the following
table:

No. Declaration Date Signature

1. 14,15,16,17 &18 September 2020