Scribd
Upload
25 views1 page

Health Declaration Form: Right To Use Granted by

This health declaration form requires all visitors to a building to provide personal details and health information to reduce the risk of COVID-19 exposure. Visitors must fill out their name, contact details, purpose of visit, whether they have symptoms or have been to high-risk areas. They also confirm they will wear a mask and undergo temperature screening. By signing, visitors declare the information is true and they will take precautions against spreading COVID-19. Staff will verify the information before granting entry to the building.

Uploaded by

faris
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
25 views1 page

Health Declaration Form: Right To Use Granted by

This health declaration form requires all visitors to a building to provide personal details and health information to reduce the risk of COVID-19 exposure. Visitors must fill out their name, contact details, purpose of visit, whether they have symptoms or have been to high-risk areas. They also confirm they will wear a mask and undergo temperature screening. By signing, visitors declare the information is true and they will take precautions against spreading COVID-19. Staff will verify the information before granting entry to the building.

Uploaded by

faris
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Health Declaration Form

In efforts of preventing the spread of Covid19 , every person who enters this building is
required to fill in this questionnaire. It is necessary that you fill in this questionnaire as a
precautionary measure to reduce the risk of exposure for all our employees and visitors.
Thank you for your cooperation.
All visitors shall finish all the information required in this Form.
Personal Details
Full Name : Age:

NRIC : Contact No. :

Gender : Male / Female Name of host :

Living Area (eg. Subang, Klang) :

Representative From (eg. Supplier ABC Company) :

Visiting Purpose (eg. Sending Goods / Meeting / Training):

2. Health Conditions:
a) Have you been to any RED ZONE area of COVID-19 over the past 14 days? YES / NO

b) Have you been in close contact with person suspected to have COVID-19? YES / NO

c) Do you attend Covid-19 positive cluster / assemblies , etc? YES / NO

d) Do you had any of the following symptoms over the past 14 days?
Please tick if yes
Fever Sore throat
Cough Difficulty in breathing

Other symptoms (please specify):

3. Checklist:
a) Wearing Mask YES / NO

b) Body Temperature

DECLARATION FROM VISITOR


I declare that the information given within this declaration of health is true and I am trying my best by
taking all the necessary precautionary measures against the spread of COVID-19 Infection.
Signature: Date:

FOR OFFICE USE ONLY


Verify By:

Right to use granted by :

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy