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DECLARATION FORM

Institution I intend to go to
I am​​

Please provide your particulars​

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

Declaration by Patient/Visitor​​

​1. Do you have a fever, cough, shortness of breath, blocked or runny nose, sore throat or cannot smell?
2. Have you had close contact with someone with COVID-19 in the last 14 days?
3. Have you travelled outside of Singapore in the last 14 days or returned from UK and/or South Africa in the past 21 days?​​
​4. Are you staying in a dormitory? (for Work Permit Holders)

5. Are you working in occupations or environment with risk of exposure to COVID-19 cases? Eg. Healthcare, Dormitory, Isolation/ Quarantine/ Community Care facilities or Ambulance/ dedicated patient transport etc
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.

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