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Health Declaration Form

This health declaration form collects information from visitors including their name, passport number, nationality, and date of arrival. It then asks a screening questionnaire to determine if the visitor has traveled from high-risk areas of COVID-19 infection, exhibited flu-like symptoms, or had close contact with someone diagnosed with coronavirus in the last 14 days. Based on their answers, visitors may be asked to wear a face mask. The visitor must sign confirming the accuracy of the information provided.

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Best Jiratip
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443 views1 page

Health Declaration Form

This health declaration form collects information from visitors including their name, passport number, nationality, and date of arrival. It then asks a screening questionnaire to determine if the visitor has traveled from high-risk areas of COVID-19 infection, exhibited flu-like symptoms, or had close contact with someone diagnosed with coronavirus in the last 14 days. Based on their answers, visitors may be asked to wear a face mask. The visitor must sign confirming the accuracy of the information provided.

Uploaded by

Best Jiratip
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Health Declaration Form: Collects visitor details and includes a screening questionnaire regarding recent travel and health symptoms related to Covid-19.

HEALTH DECLARATION FORM

VISITOR'S PARTICULARS
Name of visitors : _________________________ Company : __________________________
Passport No. : _________________________ Nationality : __________________________
Date of arrival : _________________________

SCREENING QUESTIONNAIRE

1. In the last 14 days, Which transpotation have you travelled by?


Airplane Flight No : ___________________________ YES NO
Train YES NO
Bus YES NO
Car YES NO
Others, Please specify : _______________________________________________

2. Have you travelled from any high risk destination of Covid-19 inflaction since
beginning of February, 2020?
1. China (including Hongkong, Macau) YES NO
2. Taiwan YES NO
3. Japan YES NO
4. Singapore YES NO
5. South Korea YES NO
6. Italy YES NO
7. Iran YES NO
8. Germany YES NO
9. France YES NO
10. Malaysia YES NO
11. Vietnam YES NO
Others, Please specify : _______________________________________________

3. Do you have any of the following flu like symptoms :

1. High Temperature YES NO


2. A Cough YES NO
3. Sore Throat YES NO
4. Running Nose YES NO
5. Difficulty breathing YES NO
Others, Please specify : _______________________________________________

*** if you have answered "YES" to any of the symptoms above, Please kindly wear
a face mask which are available at entrance our company ***

4. Have you been in close contact with someone who has been told
they have coronavirus (COVID-19) in last 14 days? YES NO

I hereby confirm that the above information is accurate to the best of my knowledge :

Visitor Signature: ___________________________ Date: ________________

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