Employee Self Declaration

I acknowledge that I have read and understood

Employees (the “Policy”) available at
https://jabil.sharepoint.com/en/employees/Jabil

 Language English

1) Employee Number *

Enter your answer

2) Employee Name*

Enter your answer

3) NRIC/Passport *

Enter your answer

4) Contact Tel *

Enter Contact Tel

5) Plant*

Plant 1

Plant 2

Plant 3

Plant 5

Plant 6

ICCL/BMW

Plant Batu Kawan

GBS

6) Department*

Select your answer

7) Please State whether you are experiencing

Fever, Cough, Shortness of breath or

difficulty to breath, nose block, flu, sore
throat , Nausea or Vomiting, headache,
shivering, tiredness, muscle cramps,
diarrhea, loss of smell and taste senses.

8) Please indicate your My Sejahtera,Home Lo

Red Zone

Green Zone

Others

9) Please select your My Sejahtera Risk Profile

Low Risk /Risiko Rendah

Casual Contact/Kontak Kasual

Person Under Investigation (PUI) / Orang Di B

Person Under Surveilance (PUS) / Orang Di B

Suspected Case/Kes Suspek

10) Do you know if someone staying near to yo

Have you been in contact with people being
Covid-19?
Have you attended any gathering with >20 p
Success
religious gathering, community events, celebra
Have you received call from Hospital or KKM t
YOU ARE ALLOWED TO ENTER THE
If any of the above is "Yes", then choose "Yes
PLANT.
Yes
ANDA DIBENARKAN UNTUK
MEMASUKI KILANG.
No
Date: 11/8/2021
EmpName/EmpID: Derek
Kang/1333010
11) Did you Symptoms: No
install MySejahtera App in your sm
MySejahtera Profile: Low Risk /Risiko
Yes Rendah
Suspected Case: No
No
THANK YOU AND KEEP SCREEN
SHOT AS A PROOF. / TERIMA KASIH
DAN SIMPAN SCREENSHOT SEBAGAI
BUKTI.
12) What is your MySJ ID? (Under your MySej

OK

Enter your answer

13) Why did you not install MySejahtera App?*

Select your answer

14) Are you aware that no installing MySeja

serious violation?*

Yes

No

15) Have you been vaccinated?*

Yes

No

16) Dose 1 Vaccination date*

Dose 2 Vaccination date or appointment date*

17) Have you registered for COVID-19 vaccina

Yes

No

18) Do you intend to register for the Covid 19 v

Yes

No

19) Reason for not registering for vaccination*

Select your answer

20) Do you have a confirmed vaccination date

Yes

No

21) Please enter your confirmed 1st dose date

22) Do you have history of any critical illness o

Yes

No

23) I am committed to comply with Covid-19

being to stay safe and healthy by wearing
social distancing in order to keep my family an
I hereby declare that the information provided
that any willful dishonesty may lead to disciplin

I acknowledge

Submit