Global Galaxy Food Sdn Bhd Issue Date: 09.09.

2020
Health Declaration Form

HEALTH DECLARATION FORM

1. Have you now, or have you in the last seven days, suffered from
Yes No
diarrhea/vomiting?

2. Have you suffered from fever since more than one week ago? Yes No

3. At present, are you suffering from:

i) Skin trouble affecting hands, arms or face Yes No
ii) Boils, styes or septic finger Yes No
iii) Discharges from eye, ear or gums/mouth Yes No
4. Do you suffer from:
i) Recurring skin or ear infection Yes No
ii) A recurring bowel disorder Yes No
5. In the last 5 days, have you been in contact with anyone who may have been
Yes No
suffering from cholera?

6. In the last 7 days, have you been in contact with anyone with diarrhea/vomiting? Yes No

In the last 21 days, have you been in contact with anyone who may have been
7. Yes No
suffering from typhoid or paratyphoid?
Have you been in close contact with person infected with COVID-19 in the last 7
8. Yes No
days?

I, _________________________________________ hereby declare that I am at healthy state during this

visit to Global Galaxy Food Sdn Bhd I will take full responsibility if I breach this declaration.

____________________
Signature

Date : __________________
Time : __________________
Purpose of visit :
_____________________________________________________________________________________
_____________________________________________________________________________________
NOTE: All visitor MUST REMOVE ALL accessories (eg: rings, watch and bangles) before entering the
processing area. Food & drinks are not allowed in the processing area.