HEA LTH DECLARATION FORM In efforts of prev enting the spread of Covid - 19 , every person who enters this building is required to f ill in this questionnaire. It is nece ssary that you fill in this qu estionna ire as a precautionary measure to reduce the ri sk of exposure for all employees and visitors. Thank you for your coo peration. Full Name : Mobile No. : NRI C No. : G ender : Male / Female Living Area: (e g, Taman Desa , S ri Petaling) Visiting Purpose: ( e.g. Report t o Work / Sending Goods / Deliver d ocuments) Repre sentative F r o m (e.g. Supp lier ABC Company ) **I f applica ble 2. Health Conditions: A) Have you been to any RED ZONE area o f COVID - 19 over the past 1 4 days? Y ES / NO B) Have you been in close contact with pers on suspected to have C OVID - 19? Y ES / NO C) Do you attend Covid - 19 positive cluster /assembli es , etc ? Y ES / NO D) Do you have had any of the following s ymptoms over the past 14 days? P lease tick if YES F ever Cough Sore Throat Difficulty in Breathing Other s ymptoms (please specify): 3 Check list: A) Wearing a face mask Y ES / NO B) Body Te m perat ure: De clara tion I declare that the information given within this declaration of health is true and I am trying my best by taking all the necessary precautionary measures against the spread of COVID - 19 infection. Signature: ___________________ Date: _ _________ ____ FOR OFFICE USE ONLY Verify By: