Coronavirus Self Declaration Form
For the health and safety of all guests and staff, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID19 signs.
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Travel Date
Port Embarkation / Disembarkation
*
Bintulu (MYBTU)
Kemaman Port (MYKEM)
Kuantan Port (MYKUA)
Kuching Port (MYKCH)
Kunak Port (MYKUN)
Lahad Datu Port (MYLDU)
Malacca Port (MYMKZ)
Miri Port (MYMYY)
Port Dickson (MYPDI)
Rajang Port (MYSBW)
Sungai Pakning (IDSEQ)
Tawau Port (MYTWU)
Your Traveled Destination?
HIP Oil Field
FPSO
LWP
Name
*
First Name
Last Name
Mobile Number
*
Email
*
example@example.com
Your Photo Here
*
Temperature Reading
*
Have you travelled abroad during 2020?
*
Yes
No
Name of the area(s) visited
*
Country, State, City
Dates of travel
*
Arrival and return dates for each area
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
*
Yes
No
Your relationship with the people and your last contact date with them
*
Please state whether you've experienced/are experiencing the following
*
Rows
Yes
No
Fever
1
2
Cough
3
4
Shortness of Breath
5
6
Persistent Pain in the Chest
7
8
I acknowledge that the information I've given is accurate and complete.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Prsent this code to on-board rew for varification
*
Submit
Should be Empty: