Health Screening 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?    
       
   
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.    
     
     
  Signature:    
  4/8/2020 3:54:31 PM      
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