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  • Travel History Declare Form

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    HARMET UP3 PEMATANGSIANTAR
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    A travel and contact history declaration form asks individuals if they have visited a flu pandemic area or been in close contact with a suspected flu case in the last 14 days. Close contact is defined as unprotected exposure to a confirmed case for over an hour within 2 meters. If an individual answers yes, they are asked to wait for further instructions from staff. The form collects the individual's name, identification number, temperature, and contact number.

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    A travel and contact history declaration form asks individuals if they have visited a flu pandemic area or been in close contact with a suspected flu case in the last 14 days. Close contact is defined as unprotected exposure to a confirmed case for over an hour within 2 meters. If an individual answers yes, they are asked to wait for further instructions from staff. The form collects the individual's name, identification number, temperature, and contact number.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    7 views1 page

    Travel History Declare Form

    Uploaded by

    HARMET UP3 PEMATANGSIANTAR
    A travel and contact history declaration form asks individuals if they have visited a flu pandemic area or been in close contact with a suspected flu case in the last 14 days. Close contact is defined as unprotected exposure to a confirmed case for over an hour within 2 meters. If an individual answers yes, they are asked to wait for further instructions from staff. The form collects the individual's name, identification number, temperature, and contact number.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    FORM 1: TRAVEL AND CONTACT HISTORY DECLARATION

    TRAVEL AND CONTACT HISTORY DECLARATION


    ……………………..
    Date
    Due to the current flu Pandemic you are kindly requested to read and answer the following questions:-
    Yes No
    1 Have you visited a Flu Pandemic area
    within the last 14 days?

    2 Have you been in close contact * with any person


    suspected of having flu within the last 14 days?

    If you have answered “Yes” to any of the questions, please wait for further instructions from attending staff.

    Temperature: ………………………………………..

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


    Name & Signature IC or Passport No. Contact No.

    *According to the Singapore Ministry of Health, close contacts are defied as persons who have sustained
    unprotected exposure to the confirmed case for a significant duration of time (i.e. >1 hour) and within a
    close proximity of 2 meters.

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