Health and Travel History Declaration (23rd Nov)
Staff Name
First Name
Last Name
Last 4 Digits of NRIC
Dept
Medical T1
Medical T2
Dental Team
OTC
Hospital
Admin
Acct
Support
Store
Kotra
Have you travelled overseas ie out of Singapore, in the past 7 days? (note: includes Malaysia and Batam etc)?
*
Yes
No
If Yes to the previous question, kindly fill in countries visited, duration and period
Have you been served a quarantine / isolation order / stay home notice in the last 7 days? If yes, please provide details
*
Yes
No
If Yes to the previous question, kindly fill in details
Have you been issued a medical certificate for respiratory symptoms in the last 7 days if YES indicate the MC Date below
*
Yes
No
MC Date From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MC Date To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been in close contact with a suspected/ confirmed COVID-19 case?
*
Yes
No
If Swabs test is being done for you or person staying together (eg family member, tenant etc ), please indicate the date and result if available.
Have you been to the places during the time which is visited by Cases in the Community during Infectious Period (refer to the list announced by MOH)
*
Yes
No
If Yes to the previous please details of the visit
Signature
Submit
Should be Empty: