HEALTH DECLARATION FORM

Ministry of Health Malaysia

NAMA PELABUHAN /JETI/LAPANGAN TERBANG:
Port/airport:
PEJABAT KESIHATAN DAERAH TERLBAT:
District Health:

HENDAKLAH DIISI OLEH PELAUT / SUPERNUMERARIES ITU SENDIRI. FILLED BY THE PERSON HIMSELF SEAFARER/ SUPERNUMERARIES
Nama Penuh: Pernahkah Anda Mengalami Simptom Berikut Dalam
Full Name:
Tempoh 1-14 Hari Yang Lalu? Sila Tandakan Jika Ya
Jantina: Have You Had Any Of The Following Symptoms Over The Past 1-14 Days?
Gender: Please Tick If Yes
Umur:  Demam:
Age: Fever:
 Batuk:
Cough:
No Passport /Kad Pengenalan:
Passport Number /Identity Card:
 Sukar Bernafas:
Difficulty In Breathing:
 Sakit Tekak:
Pengangkutan Diguna: Mode Of Transport: Sore Throat:
Udara Laut Darat  Symptom Lain Sila Nyatakan:
Air Sea Land Other Symptoms (Please Specify):

Nama Kapal / Nama Platform: Adakah Anda Pernah Terlibat Dengan Seseorang Disyaki
Name Of Vessel/Name Of Platform: Menghidap COVID-19? Ya/ Tidak
Tempat Berlepas Terakhir: Have You Been Involved with Person Suspected To Have COVID-19?
Last Place of Embarkation: Yes /No

Alamat Di Malaysia: Pernahkah Anda Melakukan Ujian Kendiri COVID-19?

Address In Malaysia: Ya / Tidak
No Telefon Telephone No: Jika Ya: Positif/Negatif
Have You Done Any Self-Test COVID-19? Yes/No If Yes: Positive/Negative

Tarikh Sign On / Sign Off: Adakah Anda kontak rapat kes positive COVID-19?
Sign On/Sign Off Date: Are you in close contact with COVID-19 positive cases?

Pelaut Ialah Anak Kapal Yang Bekerja Di Tapak Navigasi, Enjin, Katering,
Atau Bahagian/Jabatan Elektrik Kapal
Pelaut / Supernumeraries: Seafarers Are The Crew Members Who Work On The Navigation Site, Engine, Catering, Or Electrical
Section/Departments Of The Vessel.
Seafarer/ Supernumeraries:
Supernumeries Ialah Mereka Yang Pekerja Luar Pesisir/Platform Ialah
Mereka Yang Tidak Didokumenkan Secara Rasmi Sebagai Pelaut Dan Tidak
Melaksanakan Tugas Pelayaran Utama Kapal Di Pelayaran
Supernumeraries Are Those Who Offshore/Platform Workers Are Those Who Are Not Officially Documented As
Seafarers And Not Perform The Primary Navigational Duties Of A Ship On The Navigational

Adakah Anda Telah Mengambil Vaksin Covid- Pengesahan Pelaut / Pengesahan Pegawai Perubatan
Supernumerarieps Yang Memeriksa
19? : Ya/Tidak Confirmation Seafarer/ Supernumeraries: Confirmation Of The Medical Officer Examining

Jika Ya, Sila Nyatakan

Have You Taken The Covid-19 Vaccine? : Yes No If So, Please Specify
Jenis Vaksin Dos Kedua Tandatangan, Signature
Type Of Vaccine______________ Second Dose______________ Nama Name...................................... Tandatangan Signature
Dos Pertama Penggalak Mengaku Semua Maklumat Yang Nama & Cop Rasmi Pegawai
First Dose ______________Booster ______________ Diberikan Adalah Benar. Name & Official Stamp
Jika Perlu Kemukakan Sijil Digital Vaksin Anda I Declare All Infomation Given Are True

If Necessary Submit A Digital Certificate Of Your Vaccine SIGN OFF PELAUT / SUPERNUMERARIES DOMESTIK TIDAK PERLU
PEEGESAHAN PEGAWAI PERUBATAN
Domestic Seafarers / Supernumeraries Sign Off Does Not Require Medical Officer

KATEGORI YANG PERLU PENGESAHAN PEGAWAI PERUBATAN:

CATATAN DAN TINDAKAN Sign On Pelaut / Supernumeraries Domestik & Antarabangsa
UNTUK KEGUNAAAN Sign Off Pelaut / Supernumeraries Kapal Pelayaran Antarabangsa
PEJABAT KESIHATAN DAERAH _____________________ Categories Requiring Medical Officer Confirmation
Sign On Domestic & International Sailors / Supernumeraries
Sign Off Seafarers / Supernumeraries International voyage

Kementerian Kesihatan mengambil semua langkah berjaga-jaga yang perlu
terhadap penularan jangkitan COVID-19. Anda diminta untuk mengisytiharkan
status kesihatan anda. Seperti yang dikehendaki di bawah Seksyen 12 (1) Akta
Pencegahan dan Pengawalan Penyakit Berjangkit 1988 [Akta 342]. Mana-mana
orang yang melanggar seksyen ini, melakukan kesalahan Seksyen 12 (3) dan
Seksyen 22 (d).
Ministry of Health takes all necessary precautions against the transmission
of COVID-19 infection. You are requested to declare your health status as
required below Section 12 (1) of the Prevention and Control of Infectious
Diseases Act 1988 [Act 342].
Any person who contravenes this section, commits an offense [Section 12 (3)
and Section 22 (d)].