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(2nd File) Health - Declaration - Form - COVID-19 - MCO
(2nd File) Health - Declaration - Form - COVID-19 - MCO
(General)
5. Nationality: …………………………………………………………………….…………
• Keep this reminder for your reference while you are in working premise.
• Monitor your body temperature and look out for fever, symptom of cough and
difficulty in breathing
• If symptom worsen and you are not feeling well, seek medical treatment at the
nearest healthcare facility IMMEDIATELY.
• Cover your mouth and nose using tissue whenever you cough or sneeze.
Throw the tissue in the trash after you use it.
• Wash your hand with soap and water or use hand sanitizer regularly.
• Use face mask whenever being in public or close contact with people.
1. Have you been to any area or countries of COVID-19 as indicated by WHO or travel
interstate (from ONE state to another) over the past 14 days? Please tick if yes
Yes □ No □
3. Have you had any of the following symptoms over the past 14 days? Please tick if yes
Fever
Cough
Difficulty in breathing
Sore throat
Other symptoms (please specify) :
…………………………………………
Have you been in 1close contact with person suspected, infected and
diagnosed with COVID-19? Yes □ No □
• Health care associated exposure, including providing direct care for COVID-19 patients, working with health care workers infected with
COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient.
• Working together in close proximity or sharing the same classroom environment with a with COVID- 19 patient
• Traveling together with COVID-19 patient in any kind of conveyance
• Living in the same household as a COVID-19 patient
Signature:…………………………
Phone :…………………………
Date :…………………………