HOTAYT ELECTRONTC (M) SDN BHD

COVID 19 Self-Declaration Form (Health & Travellins Historv)

Visitors / Vendors / Suppliers

YES NO
3) ln the past 20 days, any of your family members / housemate recently
returned from other states/countries, with high cases/risks of COVID-19?
I
lf YES, specify date and location

4) Are you in close contact with anyone who is infected with covid-19?
(For eg: family/ friend/ housemate/ colleague / neighbour etc)
I
lf YES, specify name, date and location

5) Are you aware if any of your family members/friends/connections are

showing symptoms or suspected or infected with COVID-19?
lf YES , please proceed to the next question. lf NO, you may skip question 6.

6) Did you visited/meet them during their symptoms/suspension/infection

period?
lf YES, specify date and location:

7) Are you in close contact with anyone who is under quarantine (with
Covid-1 9 Quarantine Tag)?
lf YES, specify date and location:

I hereby declare that the above statements provided are true and correct. I will take all the
necessary precautionary measures to prevent the spread of COVID-19.

Name muHhmcnA\o hFn(NUL FZRIL EtN 0noH0 }{Au-(

lC. Nol Passpoil qni(ott - o8-s26, 1
Date 031ots /a42-a

Notes:-
This form applicable to atl outsider included contracfors, despatch, auditor, alstanr.r, VIP guests,
Gov offrceretc.

lf you found anoyone with Covid-l9 Quarantine tag in publip area, please report to
WhatsApp CPRC : +601 0-9699435 .
Please inform us on this incident foo, as you may have isk of infection.

Revised(6) 23 July 2020