Scribd
Upload
217 views3 pages

Ministry of Health Malaysia Health Declaration Form For Passengers On Board

The document is a health declaration form for passengers entering Malaysia that collects information about their recent travel history and any COVID-19 symptoms. It notifies passengers that under Malaysian law they are required to disclose their health status if they have visited affected countries in the last 14 days. The form asks for identifying information, travel details, and whether the passenger has symptoms or has been in close contact with someone suspected to have COVID-19.

Uploaded by

raqibsheena
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
217 views3 pages

Ministry of Health Malaysia Health Declaration Form For Passengers On Board

The document is a health declaration form for passengers entering Malaysia that collects information about their recent travel history and any COVID-19 symptoms. It notifies passengers that under Malaysian law they are required to disclose their health status if they have visited affected countries in the last 14 days. The form asks for identifying information, travel details, and whether the passenger has symptoms or has been in close contact with someone suspected to have COVID-19.

Uploaded by

raqibsheena
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/ 3

Appendix 1

Ministry of Health Malaysia

HEALTH DECLARATION FORM


FOR PASSENGERS ON BOARD

Ladies and Gentlemen,

Welcome to Malaysia.

Malaysia is taking all the necessary precautionary measures against the spread of
COVID-19 infection into our country.

If you have travelled or stayed in affected countries over the past fourteen (14) days,
you are kindly requested to declare your health status on the overleaf of this card as
required under Section 15 of the Prevention and Control of Infectious Diseases Act
1988 [Act 342]. Any person who refuses to furnish any information under this Act or
gives false information, commits an offence and if found guilty shall be punished with
imprisonment or fine or with both.

The Ministry of Health Malaysia values your sincere cooperation in this matter.

Thank You.

Director General of Health


Ministry of Health Malaysia

Disease Control Division, Ministry of Health Malaysia,


Level 3, 4, 6, Block E10, Federal Government Administration Centre,
Parcel E, 62590 Putrajaya
Tel: 03-8000 8000 Fax no: 03-8888 0643
PUBLIC HEALTH COVID-19 HEALTH DECLARATION FORM

All person entering Malaysia shall complete all the information required in this Form

PART A
(General)

1. Full name: ……………………………………………………………………………….


(Use block letters)

2. Gender: Male Female

3. Age (year/month): ………………………………………………………………………

4. Passport Number: …………………………………………………………..…………..

5. Nationality: …………………………………………………………………….…………

6. Identity Card No:…………………………………………………………………….......

7. Mode of Transport: Air Sea Land

8. Flight No./Vehicle Registration No./Name of Ship/Name of Train:

………………………………………………………………………………………..............

9. Seat No. (if applicable): ……………………………………………………………….

10. Last Place of Embarkation: …………………………………………………………...

11. Address in Malaysia: …………………………………………………………………..

………………………………………………………………………………………….........

12. Telephone No.

House: ............................... Office:...............................

Mobile:...............................
PART B
COVID-19

1. Have you been to any area or countries of COVID-19 as indicated by WHO over the past 14
days?

Yes No

2. Date of departure from the said country: ……………………………………..........

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
Sudden loss of sense of taste or smell
Other symptoms (please specify):
…………………………………………
Have you been in 1close contact with person suspected to have COVID-19?
Yes No

If the answer is yes to either of the question above, please report to the Health Screening Area.

4. Please indicate all countries and cities that you have visited or transited through in the last 14
days (including airport, ports and border crossing), providing the dates of the visit. List the
most recent countries first.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
1
Definition close contact :

 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 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:…………………………
Date :…………………………

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