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6.1 Health Declaration Form - Visitor

The document is a visitor health declaration form for a company. It collects personal details, travel and contact history, health symptoms, and temperature from visitors. Visitors must declare if they have traveled to affected countries, been in contact with those who have, attended events related to COVID19, or been in contact with suspected/confirmed COVID19 cases in the last 14 days. They must also declare if they have any symptoms like fever, cough or shortness of breath. Their temperature is taken and recorded. Visitors agree the company can collect and use this health information as a precaution against COVID19 on the premises.

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226 views

6.1 Health Declaration Form - Visitor

The document is a visitor health declaration form for a company. It collects personal details, travel and contact history, health symptoms, and temperature from visitors. Visitors must declare if they have traveled to affected countries, been in contact with those who have, attended events related to COVID19, or been in contact with suspected/confirmed COVID19 cases in the last 14 days. They must also declare if they have any symptoms like fever, cough or shortness of breath. Their temperature is taken and recorded. Visitors agree the company can collect and use this health information as a precaution against COVID19 on the premises.

Uploaded by

yy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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VISITOR HEALTH DECLARATION FORM

Personal Details

Full Name: I/C No. / Passport No.:


Purpose of visit: Contact Number:

Travel/Contact History (please " ✔" relevant box)

Have you travelled to COVID19 affected country within last 14 days? Yes No
(eg Mainland China, Hong Kong, Macau, Taiwan, South Korea, Japan,
U.S., Spain, Denmark, Italy, France, U.K., Germany, Turkey, Iran, etc)

Have you been in close contact with family, friends or individuals Yes No
who have returned from the above countries within the last 14 days?

Have you attended or come in contact with someone who attended Yes No
an event or went to a place associated with COVID19 within last 14 days?

Have you been in close contact with suspected (PUI)/confirmed case


for COVID19 within the last 14 days? Yes No

Declaration

I hereby declare that I DO NOT have the following conditions/symptoms (please " ✔" relevant box)

Symptom Yes No If No, please provide details


Fever
Cough
Shortness of breath
Runny nose
Headache
Sore throat
Other Symptoms:

I agree that the above information provided is, to the best of my knowledge, complete and true.
I agree to the collection, use and disclosure of above information by the company for the purposes of
a precautionary measure against COVID19 in the company's premises.
Name:

Signature:
Date

Acknowledge by company P.I.C.


Visitor Body Temperature

Signature: °C
Name:
Date

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