Tenant Health Declaration Form

To prevent the spread of novel coronavirus (COVID-19) in our community and reduce the risk of
exposure to all stakeholders within the mall, it is mandatory for you to answer the following simple
questionnaire.

Please submit the form to the Management via email to retailoperations@sunway.com.my for our
documentation purposes. Thank you.

Name as per NRIC/ NRIC/ Passport

Passport: Number:

Mobile Number: Nationality:

Question Self-Declaration

Have you been to any of the affected countries (Mainland China, Hong Kong, Macau, Taiwan,
1
South Korea, Japan, Italy, Germany, France, Spain, the US, Iran, Singapore, Indonesia and
Thailand) in the past 14 days?

If your answer is ‘Yes’, please observe self-

Yes No
quarantine at home for 14 days. Should
symptoms develop, please go to a designated
hospital for screening.

2 Have you been in close contact with a confirmed COVID-19 patient or Patient Under Investigation
(PUI) in the past 14 days?

If your answer is ‘Yes’, please go to a designated

Yes No
hospital for screening

3 Have you been in close proximity with any person from the affected countries?
If your answer is ‘Yes’, please observe self-
Yes No
quarantine at home for 14 days. Should
symptoms develop, please go to a designated
hospital for screening.

4 If you have the following symptom(s), please tick the relevant box(es)

No symptoms Dry cough Sore throat Running nose

Fever Shortness of Gastro-intestinal Diarrhea

breath symptoms

If you have ticked Fever AND other respiratory symptoms, please see a doctor.

If you have Fever AND respiratory symptoms, and have answered ‘Yes’ to questions 1, 2 or 3 – please go to a
designated hospital for screening.

Signature : Date :

The protection of personal data is an important concern to Sunway Malls and any personal data collected on this form will be treated in accordance
with Personal Data Protection Notice of the company (http:www.sunway.com.my/group/privacy.asp).