1. Adakah anda mengalami gejala-gejala respiratori berikut?

Do you have these respiratory symptoms?

a) Batuk / Cough Ya / Yes Tidak / No

b) Selsema / Flu Ya / Yes Tidak / No

c) Sesak nafas / Shortness of Breath Ya / Yes Tidak / No

d) Kesukaran bernafas / Difficulty in Breathing Ya / Yes Tidak / No

e) Hilang deria bau tiba-tiba / Sudden new onset Ya / Yes Tidak / No of

anosmia (loss of smell)

f) Hilang deria rasa tiba-tiba / Sudden new onset Ya / Yes Tidak / No of

ageusia (loss of taste)

2. Adakah anda mengalami gejala-gejala bukan respiratori berikut?

Do you have these non-respiratory symptoms?

a) Demam / Fever Ya / Yes Tidak / No

b) Menggigil / Chills Ya / Yes Tidak / No

c) Tegang otot / Rigors Ya / Yes Tidak / No

d) Sakit-sakit badan / Myalgia Ya / Yes Tidak / No

e) Sakit kepala / Headache Ya / Yes Tidak / No

f) Sakit tekat / Sore threat Ya / Yes Tidak / No

g) Loya dan muntah-muntah / Nausea or Vomit Ya / Yes Tidak / No

h) Cirit-birit / Diarrhoea Ya / Yes Tidak / No

i) Keletihan / Fatigue Ya / Yes Tidak / No

*Definition of close contact:

• Health care associated exposure, including providing direct care for COVID-19 patients, working with healthcare 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.
• Travelling together with COVID-19 patient in any kind of conveyance.
• Living in the same household as a COVID-19 patient.
 j) Situasi akut hidung tersumbat atau berair / Ya / Yes Tidak / No
Acute onset of nasal congestion or running nose

3. Adakah anda pernah disahkan positif COVID-19?

Have you been declared as a positive COVID-19?
Ya / Yes Tidak / No

4. Adakah anda mempunyai kontak rapat dengan Ya / Yes Tidak / No

mereka yang POSITIF COVID-19?
Do you have a history of close contact* with
anyone who has been diagnosed as COVID-19
POSITIVE within 14 days before onset of illness?

5. Adakah anda mempunyai sejarah perjalanan ke luar Ya / Yes Tidak /

No negara dalam tempoh 14 hari yang lepas?
Do you have a history of travelling to or coming from
overseas / any red zone areas / areas associated
with known COVID-19 cluster as declared by KKM for
the last 14 days?

6. Adakah anda sedang menjalani perintah kawalan Ya / Yes Tidak / No

kuarantin di rumah yang diarahkan oleh
Kementerian Kesihatan Malaysia?
Are you currently under strict home quarantine as
instructed by the Ministry of Health Malaysia?

*Definition of close contact:

• Health care associated exposure, including providing direct care for COVID-19 patients, working with healthcare 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.
• Travelling together with COVID-19 patient in any kind of conveyance.
• Living in the same household as a COVID-19 patient.
 Saya mengesahkan bahawa semua maklumat yang diberikan adalah
betul dan tepat. Tindakan boleh dikenakan jika maklumat yang
diberikan adalah palsu.

I hereby declare that all the information given in this form is true and
correct. Action can be taken if the information provided is false.

Nama / Name : ………………………………………………………………………………………………………

No. KP / NRIC : ………………………………….. No. Tel / Tel No. : ……………………………………

No. ID Pelajar / : …………………………………………………………………………………………………….

Student ID No.

IPT / HEI : ………………………………………………………………………………………………………

Campus / Campus :
………………………………………………………………………………………………………

Tandatangan / Signature : …………………………….…………………….

Tarikh / Date : - -
h h b b t t t t
d d m m y y y y

*Definition of close contact:

• Health care associated exposure, including providing direct care for COVID-19 patients, working with healthcare 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.
• Travelling together with COVID-19 patient in any kind of conveyance.
• Living in the same household as a COVID-19 patient.