Name: NURUL FAJRIAH AFIATUNNISA

NRIC/Passport No: A 8467734

Email & Mobile: sssgirl0@gmail.com
(+6285344729075)
IMPORTANT: ALL Students to return completed record ONE (1) week prior to start of electives
via email.
Screening Record (Overseas Elective Students)
Date:

1a.

Do you have flu-like symptoms (i.e. fever and / or cough) in the last 14
days?

Yes / No

If Fever, state highest recorded Temp: _______ and date: __________.

Current Temperature: ____________________________
(State NA if temperature not taken)

(Please
circle
accordingly)

Have you travelled or lived overseas in the last 14 days before the onset
of symptoms?
1b.

If yes,
Countries1 (Middle Eastern):__________________
Countries (Others) : _____________________________________

Yes / No
(Please
circle
accordingly)

Have you travelled to or stayed in Africa2 and developed a fever in the

last 21 days?

2.

If yes, Countries:_____________________________________________
If Fever, state highest recorded Temp: _______ and date: __________.
Current Temperature: ____________________________
(State NA if temperature not taken)

Yes / No
(Please
circle
accordingly)

State any other Symptoms: _____________________________________

_____________________________________
Do you intend to travel to any of the listed countries1,2 in the coming few
weeks before your arrival in Singapore?
3.
If yes,
Countries : _____________________________________

Yes / No
(Please
circle
accordingly)

Associate Deans Office (ADO) | 2 June 2015

4.

Contact Details of Next-of-Kin

Name
(1) Buhaeriyah

Relationship
Mother

Contact (Email & Mobile)

buhaeriyah@gmail.com
+6281344203155

(2)
1 High Risk Countries (for MERS-CoV) Middle Eastern: Jordan, Kuwait, Lebanon, Oman,
Qatar, Saudi Arabia, United Arab Emirates & Yemen
2 High Risk African Countries (for Ebola) include: Guinea & Sierra Leone
SELF-SURVEILLANCE GUIDELINES (14 days prior to commencement of electives)

1. Check your temperature three times a day (8am, 12pm, 8pm).

2. Observe good personal hygiene such as covering the mouth / nose with a tissue when
coughing / sneezing.
3. Wash your hands often and thoroughly.
4. If you have flu-like symptoms and fever of 37.5 degrees Celsius and above, please put on a
mask and seek medical attention at the nearest medical centre.
5. To avoid all overseas travel and seek medical treatment in your country until symptoms clear
up.

Associate Deans Office (ADO) | 2 June 2015