Report of Confirmed

COVID-19 Case or
Closed Contact Case
(Rev: 0004) w.e.f 4th
APRIL 2022
Do provide details as required for company's
record. If a COVID 19 cluster is detected at a
particular premises, prompt action is
required to report to the nearest District
Health Ofce. Thank you for your
cooperation.
From : KHI EMD
#ReopeningSafely

halimatussaadiah9192@gmail.com
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Email *

Your email address

This is a required question

Report of COVID-19 Status *

Con1rmed C19 Case (RTK/PCR result -

Detected)

Closed Contact to Con1rmed Case or

Suspected Case of C19

1) Full Name (CAPITAL LETTER): *

ROSLAN BIN ABD RASHID

2) NRIC (XXXXXX-YY-ZZZZ) or Passport *

Number :

831016015491

3) Date of Birth (mm/dd/yyyy) *

DD MM YYYY

16 / 10 / 1983

4) Age *

39

5) Gender *

Female

Male

6) Contact Number: *

01136365346

7) Residential Address: *

BLOK J-3-14 PANGSAPURI PUTRA

INDAH,TAMAN PINGGIRAN PUTRA

8) Nationality *

Malaysian

Vietnamese

Bangladeshi

Nepalese

Burmese (Myanmar)

Indonesian

Other:

9a) Occupation/Job Title *

Example: Machine Operator

WAREHOUSE

9b) Department/Line *

HITACHI WAREHOUSE

10) Place of Working - Which factory? *

Factory A (Lot 1837, Jalan Kolej, 43300

Seri Kembangan, Selangor)

Factory B (Lot 1863, Jalan Kolej, 43300

Seri Kembangan, Selangor)

Factory M (Lot 1866, Jalan Kolej,

43300 Seri Kembangan, Selangor)

Factory Lot 33 (Lot 33, Jalan 6/2,

Kawasan Perindustrian Seri
Kembangan, 43300 Seri Kembangan,
Selangor)

Factory Lot 44 (Lot 44, Jalan 6/2,

Kawasan Perindustrian Seri
Kembangan, 43300 Seri Kembangan,
Selangor)

11) Last working day (mm/dd/yyyy) : *

DD MM YYYY

27 / 09 / 2022

12a) Any C19 symptoms? *

Yes

No

12b) If Yes, What symptoms?

Fever

Shortness of Breath

Cough

Loss of Taste

Loss of Smell

Chills /Rigors

Muscle aches & pain

Headache

Sore Throat

Nausea/Vomiting

Diarrhoea

Fatigue

Running Nose / Congestion

Other:

12c) Date symptoms started?

(mm/dd/yyyy)

DD MM YYYY

27 / 09 / 2022

13a) Any other medical problems eg. *

High Blood pressure, Diabetes, Asthma
etc. : Yes/No

Yes

No

13b) If Yes, list of the medical problems :

Your answer

14a) Vaccination done? *

Yes

No

14b) If yes, Type of Vaccine for First and *

Second Dose? :

AstraZeneca

P1zer

Sinovac

Other:

14c) How many dose done? : *

First Dose

Second Dose

Booster Dose

14d) First Dose Date ? *

(mm/dd/yyyy)

DD MM YYYY

17 / 07 / 2021

14e) Second Dose Date ? *

(mm/dd/yyyy)

DD MM YYYY

07 / 08 / 2021

14f) Booster Dose Date?

(mm/dd/yyyy)

DD MM YYYY

/ /

15a) Any closed contact with person *

tested positive ?
If yes, do share us the RTK or PCR test report
or RTK self test result or screenshot of
MySejahtera C19 Risk Status

Yes

No

15b) If yes, list out the Full Name and

Relationship

Your answer

15c) Date of Last Contacted

(mm/dd/yyyy)

DD MM YYYY

/ /

16a) CONTACT TRACING FOR *

WORKPLACE: Do check out any of KHI
Staff(s) had closed contacted with you
recently ?

Yes

No

16b) If yes, when was your last close

contacted with those KHI staff(s)
(mm/dd/yyyy) ?

DD MM YYYY

/ /

16c) If yes, list out the name(s) of KHI

staff(s) that you had close contacted

Your answer

17a) Type of Test Done *

RTK

PCR

17b) Sampling Date (mm/dd/yyyy) *

DD MM YYYY

28 / 09 / 2022

17c) Result Date (mm/dd/yyyy) *

DD MM YYYY

28 / 09 / 2022

17d) Testing Location (Self Test, PKD, *

Clinic, Laboratory). Please specify

Laboratory

17e) Sample Result *

For Detected Case, do share us the RTK or
PCR test report or RTK Self Test result and
screenshot of MySejahtera C19 Risk Status

Detected

Not Detected

17f) Upload the Test Report or Picture of *

RTK Self Test result

48A7948C-EC34-…

18a) Had received KKM Letter or *

MySejahtera Status for Home
Surveillance Order (HSO) ?

Yes

No

18b) If received HSO, please specify the

HSO Start Date to End Date (mm/dd/yyyy)
Please share the screenshot of MySejahtera
Digital HSO and Digital Completed HSO.
For closed contact quarantine,
to share us the screenshot of My Sejahtera
Closed Contact Risk Pro1le.

Your answer

18c) Upload Digital HSO. *

For Closed Contact Case, can upload

RTK Self Test Test Result if do not have
Digital HSO.

4CC87053-BADD…

18d) Admitted to Hospital/ PKRC *

MAEPS?

Yes

No

18e) If admitted to Hospital/ PKRC

MAEPS, specify the date of admission
(mm/dd/yyyy)
To submit the Release Order/Discharge Note
when report to work

DD MM YYYY

/ /

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