HEALTH DECLARATION FORM

Dear Sir/Madam

To prevent the spread of Wuhan Virus in our community and to reduce the risk of exposure to our
staff and visitors, we would like you to answer a few Wuhan Virus-related questions on this form.
_________________________________________________________________________________

1 Do you have fever, breathing difficulties, cough? Yes No

2 (a) Did you have any contact with a Wuhan Virus patient Yes No
in the past 14 days?

(b) Did any one of your immediate family members have Yes No
contact with a Wuhan Virus patient in the past 14 days?

3 (a) Have you, your spouse and/or close family member(s) Yes No
living in the same household travelled, in the past 14
days, to any of the Wuhan Virus affected
areas?

(b) If yes to 3(a), please state country of visit. _________________

Thank you for your understanding and co-operation.

_________________________________________________________________________________

I declare that the information given above is true and correct to the best of my knowledge and that I
have not withheld/distorted any information.

Name: _____________________________ NRIC No. (last 4 digits): _________________

Date/Time: __________________________ Company: ____________________________

Contact No: _________________________ Signature: ____________________________

Temperature Reading (if required) / Record by staff: __________________________________

Taking Temperature of Visitors

Temperature taking should be done if a visitor answers “Yes” to any of the questions
above or appears unwell.

If visitor’s temperature is above 37.5º C, he should be advised to seek medical

attention and should not be allowed to enter the office and workplace.