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DECLARATION FORM​​​

Date
Institution I intend to go to
I am​

Please provide your particulars

Your Name​
Your NRIC / FIN / Passport
Mobile No
I am going to

Declaration by Patient/Visitor

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


2. Do you have flu-like symptoms (e.g. fever, cough, runny nose, sore throat or loss of taste / smell, etc.)?

3. Are you currently serving:
(i) Stay-Home Notice (SHN); OR
(ii) Quarantine Order (QO) issued by the Ministry of Health (MOH)?


4. Have you been admitted to or visited Tan Tock Seng Hospital (TTSH)’s Inpatient Wards from 18 April 2021
OR
Have you visited TTSH A&E on 18 or 19 April 2021?



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.