Health Declaration Form

Name

First NameMiddle NameLast Name

Nationality

Sex

MaleFemale

Age

Contact Number

Landline or Mobile Number

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Foreign countries you have worked, visited, transited in the past 14 days

Enter 'None' if not applicable. Please separate countries with a comma ( , )

Cities you have worked, lived or transited in the past 14 days

Enter 'None' if not applicable. Please separate countries with a comma ( , )

Have you been sick in the past 30 days?

YesNo

If Yes, please describe your condition and what hospital did you visit, if any?

In the last 14 days, did you have any of the following: fever, colds, cough, sore throat, loss of smell and taste, muscle pain, headache or difficulty in breathing?

YesNo

If Yes, please specify these

In the last 14 days, have you been in close contact or exposed to any person suspected of or confirmed with COVID-19?

YesNo

If Yes, please describe the circumstances

In the last 14 days, have you been in close contact with farm animals or exposed to wild animals?

YesNo

If Yes, please describe the circumstances

Declaration and Data Privacy Consent Form:

By signing this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalized in accordance with the law.

I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to COVID-19 business operation requirements and in accordance with the Data Privacy Act. For any concerns, you may contact example@example.com.

Date

Hour MinutesAM/PM Option

Signature