Skip Ribbon Commands
Skip to main content
Menu

DECLARATION FORM​​​

Date
Institution I intend to go to
I am​

Please provide your particulars

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

Declaration by Patient/Visitor

1. Have you travelled abroad (i.e. to any countries outside of Singapore, excluding Brunei and New Zealand) 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:
(i) serving  Stay-Home Notice (SHN); OR
(ii) serving Quarantine Order (QO) issued by the Ministry of Health (MOH)?
(iii) a Person Under Phone Surveillance (PUPS) by MOH?

4. In the past 14 days:
  1. did you receive a MOH Health Risk Warning SMS or a MOH Health Risk Alert SMS; OR
  2. have you had close contact  with a COVID-19 person?

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.