COVID-19 OUTBREAK CONTROL PRE-ARRIVAL DECLARATION

FOR CONTRACTOR

CONTRACTOR

Full completion of this form is mandatory.

Maklumat lengkap adalah wajib.

1. Expected Arrival Date *

Jangkaan Tarikh Ketibaan

10/18/2021

2. Name *
Nama

MUHAMMAD HADI AFFANDY BIN MD NAJIB

3. Email address *
Alamat E-Mel

hadiaffandy96@gmail.com

4. NRIC or Passport No. *

KP atau No. Pasport

900501036209

5. PIC Access Card No *

No. Kad Akses PIC
 CP010266

6. Phone No. *
No. Telefon

1121839693

7. Operating Company (OPC) *

Syarikat Operasi

GLOBAL TESTING SERVICES (M) SDN BHD

8. Name of Host *
Name Penganjur

SITI RUBAIYAH BINTI MOHD ISA

9. Host Phone No. *

No Telefon Penganjur

0134880858

Section

10. Travel Origin Address *

Alamat Tempat Mula Perjalanan

BANDAR PENAWAR

11. MySejahtera Risk Classification *

Pengelasan Risiko Mysejahtera

 Low

High

12. Travelling Start Date *

Tarikh Mula Perjalanan

10/18/2021

13. Travelling End Date *

Tarikh Tamat Perjalanan

10/18/2021

14. Destination Address

Alamat destinasi

PIC

Approving Authority (AA)

Pihak Berkuasa Melulus

15. Vaccination Status *

Status Vaksin Covid-19

Fully vaccinated with e-certificate

Awaiting for 2nd dose vaccination

Awaiting for vaccination appointment

Not vaccinated for specific reason

Others
16. Targeted Green Bubble Entry
*
Interaction with staff or contractors at P1(RFCC 1 & 2) or P2 (ARDS 1 & 2) or P3(DHT).  
Kemasukan ke ‘Green Bubble’ Bersasar

Interaksi Bersama kakitangan atau contractor di P1(RFCC 1 & 2) atau P2 (ARDS 1 & 2) atau P3(DHT).

Yes

No

17. OPU/Tenant/Division of the AA *

Unit Operasi/Penyewa/Bahagian Pihak Berkuasa Melulus

PREFCHEM Contractor AMT CMT (Electrical C… 

Details on RTK-Antigen / RT-PCR test

Butiran tentang ujian RTK-Antigen / RT-PCR

18. Test result date *

Tarikh keputusan ujian

10/10/2021

19. Test result time *

Masa keputusan ujian

15:22 PM

20. Name of the clinic and location *

Nama dan lokasi klinik

KLINIK MEDIVIRON SEKSYEN 7

21. Name of the doctor validated the negative test result *

Nama doktor yang meluluskan keputusan negatif ujian
 SW ARNAMUGI A/P SELVARAJOO

22. I declare Vaccination Certificate/Negative RTK-Antigen result / Negative RT-PCR test result

/ Release letter from MOH  submitted to my superior/area manager/contract owner 
*
Saya mengakui Sijil Vaksin atau keputusan ujian RTK-Antigen negatif/RT-PCR negatif atau surat perlepasan KKM 
 telah dihantar kepada pihak atasan/ketua Kawasan/pemilik kontrak

Yes

23. I declare that negative RTK Antigen/RT PCR test is eligible and conducted within 24 hours
prior arrival to PIC
*
Saya mengakui bahawa keputusan RTK Antigen/RT PCR negatif adalah benar dan dilakukan dalam tempoh 24 jam
sebelum ketibaan ke PIC

Yes

Please answer the questions and tick where appropriate.

Sila jawab soalan di bawah dan tandakan mana yang berkenaan

24. Personal History *

Sejarah Perjalanan

Were you tested positive for COVID-19 in the past 1 month?

Adakah anda pernah disahkan positif untuk COVID-19 dalam tempoh 1 bulan yang lalu?

No

 Yes

 No

Have you had contact with any suspected or confirmed COVID-19 case in the past 1 month?
(e.g. family members, friends, neighbours, congregation)

Adakah anda pernah bersemuka dengan mana-mana individu yang disyaki atau disahkan
positif COVID-19 dalam tempoh 1 bulan yang lalu? (spt. ahli keluarga, rakan, jiran, ahli jemaah)

No
 Are you currently serving Home Surveillance Order (HSO)?

Adakah anda sedang menjalani Pengawasan dan Pemerhatian di Rumah?


No

Have you visited any areas classified under Enhanced MCO in the past 1 month?

Adakah anda pernah melawat lokasi yang diisytiharkan sebagai kawasan PKPD dalam tempoh 
1 bulan yang lalu?

No

Are there any known active cases in your company / department or your work area currently?

Adakah syarikat/jabatan atau di kawasan kerja anda sekarang mamunyai kes aktif COVID-19?

No

Please answer the questions and tick where appropriate.

Sila jawab soalan di bawah dan tandakan mana yang berkenaan

25. CLOSE CONTACT HISTORY *

SEJARAH PERJALANAN KONTAK RAPAT

Note: Referring to person who are staying with you, travelled with or met in the past 1 month

Nota: Merujuk kepada individu yang tinggal bersama anda, melakukan perjalanan bersama atau berjumpa dengan
anda dalam tempoh 1 bulan yang lalu

Have any of your close contacts done swab test in past 1 month?

Adakah kontak rapat anda pernah menjalani ujian saringan dalam tempoh 1 bulan yang lalu?

No

 Yes

 No

Have any of your close contacts had contact with any suspected or confirmed COVID-19 case
in the past 1 month?

Adakah kontak rapat anda pernah bersemuka dengan mana-mana individu yang disyaki atau
disahkan positif COVID-19 dalam tempoh 1 bulan yang lalu?

No

Are any of your close contacts currently serving Home Surveillance Order (HSO)?

Adakah kontak rapat anda sedang menjalani Pengawasan dan Pemerhatian di Rumah

No
 Have any of your close contacts been in close contact with any known COVID-19 clusters in

past 1 month?

Adakah kontak rapat anda pernah menjadi kontak rapat dengan mana-mana kluster COVID-19
dalam tempoh 1 bulan yang lalu?

No

Have any of your close contacts visited any areas classified under Enhanced MCO in the past 1
month?

Adakah kontak rapat anda telah pergi ke kawasan yang diisytiharkan sebagai kawasan PKPD
dalam tempoh 1 bulan yang lalu?

No

Section

26. MINOR SYMPTOPMS *

GEJALA RINGAN

Do you have any of the following symptoms?

Adakah anda mempunyai simptom berikut?

a. Fever
(Demam)

No

 Yes

 No

b. Sore Throat (Sakit Tekak)


No

c. Nasal Congestion or Runny Nose

(Hidung tersumbat atau berair)

No

27. MAJOR SYMPTOMS *

GEJALA BERAT

Do you have any of the following symptoms?

Adakah anda mempunyai simptom berikut?

a. Cough


 (Batuk)
No

 Yes

 No

b. Shortness of Breath

(Sesak Nafas) 
No

c. Difficulty in Breathing

(Sukar untuk Bernafas) 

No

d. Sudden loss of smell

(Hilang deria bau secara tiba-tiba)


No

e. Sudden loss of taste

(Hilang deria rasa secara tiba-tiba) 

No

Declaration
In accordance with Malaysia’s Personal Data Protection Act 2010 and the EU General Data Protection Regulation (GDPR),
your personal or sensitive data is being collected for the purpose of workplace infection control in relation to the COVID-19
outbreak originating from China.

Merujuk kepada Akta Perlindungan Data Peribadi 2010 dan EU General Data Protection Regulation (GDPR), maklumat
peribadi dan data sensitif dikumpulkan untuk tujuan kawalan penyakit berjangkit berkaitan pandemik COVID-19 yang
bermula di negara Cina.

28. I consent to the collection and processing of my data for the above purpose *
Saya bersetuju pengumpulan dan pemprosesan data peribadi saya untuk tujuan di atas

Yes

29. I declare that my close contacts and I did not engage in any activities or have any contacts
that may potentially expose us to COVID-19
*
Saya mengakui bahawa saya dan kontak rapat saya tidak terlibat dalam sebarang aktiviti yang berpotensi untuk
menjangkiti kami dengan COVID-19.

Yes

30. I agree that all information declared are accurate and any false declaration could result in
consequence management.
*
Saya mengakui semua maklumat adalah benar dan tindakan boleh dikenakan ke atas saya jika maklumat diberikan
didapati palsu atau tidak benar.

Yes

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