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    Health Declaration Form: Borang Pengisytiharan Kesihatan

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    hasan mamat
    This document is a health declaration form asking individuals about their COVID-19 status and risk factors. It asks if they are experiencing symptoms, have previously tested positive, had close contact with someone who tested positive, traveled internationally in the last 14 days, or are currently under home quarantine. The individual must declare that the information provided is true and correct, and that legal action can be taken if any information is false. It also defines what is considered a close contact.

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    Health Declaration Form: Borang Pengisytiharan Kesihatan

    Uploaded by

    hasan mamat
    44 views1 page
    This document is a health declaration form asking individuals about their COVID-19 status and risk factors. It asks if they are experiencing symptoms, have previously tested positive, had close contact with someone who tested positive, traveled internationally in the last 14 days, or are currently under home quarantine. The individual must declare that the information provided is true and correct, and that legal action can be taken if any information is false. It also defines what is considered a close contact.

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    This document is a health declaration form asking individuals about their COVID-19 status and risk factors. It asks if they are experiencing symptoms, have previously tested positive, had close contact with someone who tested positive, traveled internationally in the last 14 days, or are currently under home quarantine. The individual must declare that the information provided is true and correct, and that legal action can be taken if any information is false. It also defines what is considered a close contact.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    44 views1 page

    Health Declaration Form: Borang Pengisytiharan Kesihatan

    Uploaded by

    hasan mamat
    This document is a health declaration form asking individuals about their COVID-19 status and risk factors. It asks if they are experiencing symptoms, have previously tested positive, had close contact with someone who tested positive, traveled internationally in the last 14 days, or are currently under home quarantine. The individual must declare that the information provided is true and correct, and that legal action can be taken if any information is false. It also defines what is considered a close contact.

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    BORANG PENGISYTIHARAN

    KESIHATAN /
    HEALTH DECLARATION FORM

    1. Adakah anda mengalami gejala-gejala berikut?


    Do you have these symptoms?
    a) Demam / Fever Ya / Yes Tidak / No
    b) Batuk / Cough Ya / Yes Tidak / No
    c) Selsema / Flu Ya / Yes Tidak / No
    d) Sesak nafas / Difficulty in breathing Ya / Yes Tidak / No

    2. Adakah anda pernah disahkan positif COVID-19? Ya / Yes Tidak / No


    Have you being declared as a positive COVID-19?

    3. Adakah anda mempunyai kontak rapat dengan


    mereka yang disahkan POSITIF COVID-19? Ya / Yes Tidak / No
    Do you have history of close contact with anyone who
    has been Diagnosed as COVID19 POSITIVE?

    4. Adakah anda mempunyai sejarah perjalanan ke luar Ya /Yes Tidak / No


    negara dalam tempoh 14 hari yang lepas?
    Do you have history of travelling to overseas for the last 14
    days?

    5. Adakah anda sedang menjalani perintah kawalan


    kuarantin di rumah yang diarahkan oleh Kementerian Ya / Yes Tidak / No
    Kesihatan
    Malaysia?
    Are you currently under strict home quarantine as
    instructed by Ministry of Health Malaysia?

    Saya mengesahkan bahawa semua maklumat yang diberikan adalah betul dan tepat.
    Tindakan boleh dikenakan jika maklumat yang diberikan adalah palsu.

    I hereby declare that all the information given in this form is true and correct. Action can be
    taken if the information provided is false.

    Nama / Name :………………………………………………………………………………………………………

    No. KP / NRIC:……………………………………….................No. Tel:………………………………………….

    IPT:……………………………………………………................Tarikh / Date:.................................................

    T/Tangan / Signature :
    Definition close contact :
    • Health care associated exposure, including providing direct care for COVID-19 patients, working with
    health care workers infected with COVID-19, visiting patients or staying in the same close environment
    of a COVID-19 patient.
    • Working together in close proximity or sharing the same classroom environment with a with COVID19
    patient
    • Traveling together with COVID-19 patient in any kind of conveyance
    • Living in the same household as a COVID-19 patient.

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