NOVEL CORONAVIRUS (nCOV)

Health & Travel Declaration Form

The World Health Organization (WHO) has issued a global alert on the outbreak of Novel Coronavirus. In our
nationwide drive to curb the spread of this virus, all of us are socially responsible for the benefit of the
community. Please complete the Declaration Form and hand it to your host/reception/security guard on duty before
entering the premises. All information provided would be kept strictly confidential.

Guest Name: ______________________________________

Mobile Number: ______________________________________

Company: ______________________________________

Host Name: _______________________________________

Please answer ALL the questions:

1. Do you have symptoms of fever, cough, chills/shivering, muscle aches and breathing difficulties?

( ) No
( ) Yes

2. Have you visited any hospitals, clinics or had visited nCOV patients recently?

( ) No

( ) Yes - Please specify: __________________________________________

3. In the past two weeks, have you been served with home quarantine orders or otherwise told to stay at home?
( ) No

( ) Yes - Please specify: _________________________________________

4. Did you return from China or any other countries within the last 14 days? If yes, please provide details:
Period: From ___________ to ______________

Country traveled to : ______________________

Flight/Vessel Name or No: _____________

5. Do you have any members living in the same household been quarantined for nCOV?

( ) No
( ) Yes Please specify who and when: ____________________________________________

6. Do you have any members living in the same household that are likely to exposed to nCOV risk? Such as
travelling to affected countries or working in hospitals?

( ) No
( ) Yes Please provide details: __________________________________________________

___________________ _____________
Signature Date

Health & Travel Declaration - VE