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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)?


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.