Health Screening & Travel Declaration Form  
To prevent the spread of COVID-19 virus in our community and reduce the risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire.  Your participation is important to help us take precautionary measures to protect you and everyone in the building as well as for use during contact-tracing. Thank you for your time.
Name *      
Personal Contact Number required *      
Your Location required *      
NRIC *      
Purpose of Visit required *        
1. Do you have the following symptom(s) such as fever, cough, sore throat, runny nose ?    
2. Have you or your family member been in contact with a confirmed COVID-19 patient in the past 14 days?    
3. Have you or your family member(s)/people you are living with , travelled overseas in the last 14 days?    
4.Are currently serving Stay-Home Notice or Quarantine Order or Health Risk Warning” (HRW) or “Health Risk Alert” (HRA) issued by MOH?    
5. You are *NOT* vaccinated or you will *NOT* be able to produce ART negative or PCR negative report ?    
I confirm that the above information is correct and accurate. I also understand that    omitting or providing false information is an offence under the Infectious Disease Act.    
  10/29/2021 4:01:51 AM      
  SMMP-MP-F-04, Ver 1.00 Rev 00, 01 June 2020