PANGSAPURI DE BAYU

(Property Managed by PMC Facilities & Real Estate Sdn Bhd)

Management Office, No. 2, Persiaran Setia Makmur,
Setia Alam, Seksyen U13, 40170 Selangor Darul Ehsan.
Tel: 03-3885 3858 Email: debayu-pm@spsetia.com

HEALTH SCREENING FORM FOR VISITOR,

CONTRACTOR & SERVICE PROVIDER
Dear Sir/Madam,

To prevent the spread of COVID-19 in our community and reduce the risk of exposure to any person,
we are conducting a simple screening questionnaire. Your participation is important to help us take
precautionary measures to protect you and everyone in this building.

*Owner’s Name : *Contact No: *House Unit:

*Service Provider’s/Contractor’s Name: *Contact No: *Temperature Reading:
(1) (1) (1)
(2) (2) (2)
*Time In:
*Reason:

Service Provider / Contractor - Self Declaration Service Provider / Contractor - Self Declaration
(1) Name: (2) Name:
If you have the following symptom(s), If you have the following symptom(s),
please circle your answer: please circle your answer:
Sore Sore
Fever Cough Shortness of Breath Fever Cough Shortness of Breath
Throat Throat
Others Others
No Symptom No Symptom
___________________ ___________________
Have you been in contact with any COVID-19 cluster Have you been in contact with any COVID-19 cluster
declared by MOH or Person Under Investigation declared by MOH or Person Under Investigation
(PUI) or confirmed COVID-19 patient in the past 14 (PUI) or confirmed COVID-19 patient in the past 14
days? days?
Yes No Yes No
Have you been to affected COVID-19 countries or Have you been to affected COVID-19 countries or
area(s) in the past 14 days? area(s) in the past 14 days?
Yes No Yes No

If yes, please indicate the affected country(s) or If yes, please indicate the affected country(s) or
area(s) : _______________________ area(s) : _______________________
Vaccine Status: Vaccine Status:
1st Dose Complete Vaccine 1st Dose Complete Vaccine
Not Registered for Vaccine Not Registered for Vaccine
ATTENTION:
● If you have answered "Yes" to any of the questions above or temperature above 37.5 degrees
Celsius, access to the De Bayu Apartment will be DENIED. Please sign and returned this form to
De Bayu Management Office.

Owner’s Signature : Date : For Management Office Approval

Name:
Date:
*Note : Information Captured is used for contact tracing if required. Signature:
Thank you for your time and cooperation.