SERIAL NO: AMY/SAFETY/FORM/2022/002

Visitor/Contractor Health Declaration

Name :
IC No. :
Company Name :
Store/mall :
Workplace :
Working Period : ____ /_____ /_______ to _____ /______ /______
Time : _______am/pm to _________am/pm
Emergency Contact :
person & Contact No

Please tick YES (/) or NO (X) to answer below question:

1. Have u ever suffer or diagnose any serious health problem (heart problem,
lung problem, stroke & High blood pressure, diabetes & etc)?
If yes (/), please put in remark ………………………………………………

2. Did you suffer any serious body injury (broken bone, damage tissue/ligament)?
If yes (/), please put in remark ………………………………………………

3. Have you undergone/ have been recommended to undergo major surgery or

treatment?
If yes (/), please put in remark ………………………………………………

4. Are you in good condition and fit to work the whole working period? (no injury,
no sickness like fever, flu, sore throat)
If No (X), please put in remark ………………………………………………

5 Any other health sickness that could affect the work task and accident may
Occur?
If yes (/), please put in remark ………………………………………………

I __________________________________ with IC number ___________________hereby

declare that all above information given in Visitor/Contractor Health Declaration Form are
true and correct to the best of my knowledge.
Prepared by, Verified by,

Contractor/Visitor Security on Duty

*AEON Co. (M) Bhd reserves the right to refuse entry to the premise as deemed necessary.