DECLARATION FORM

Institution I intend to go to

I am

Patient Name

Please provide your particulars

Your Name

Your NRIC / FIN / Passport

Mobile No

I am going to

Location Others

Date

Declaration by Patient/Visitor

1. Have you travelled abroad (i.e. to any countries outside of Singapore) in the past 14 days?

Yes
No

2. Do you have flu-like symptoms (e.g. fever, cough etc.)?

Yes
No

3. Did you, in the past 14 days, come in close contact with someone who
(i) Is a confirmed COVID-19 case; OR
(ii) Is part of a COVID-19 cluster?

Yes
No

4. Have you returned from the Middle East* in the past 14 days?
*High Risk Middle Eastern Countries (for MERS-CoV) include: Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates & Yemen

Yes
No

5. Did you come in contact with someone who has returned from Middle East and he/she is not feeling well in the past 14 days?

Yes
No

The information you provide is important in managing the risk of COVID-19 transmission. The Infectious Diseases Act requires a person who has reason to suspect that he is a case or carrier of COVID-19, or has had contact with a person with COVID-19, to act in a responsible manner to not expose other persons to the risk of infection by the disease.