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DECLARATION FORM

Date

Institution I intend to go to

I am

Patient Name

Please provide your particulars

Your Name

Your NRIC / FIN / Passport

Mobile No

I am going to

Location Others

Declaration by Patient/Visitor

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

Yes
No

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

Yes
No

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?

Yes
No

4. In the past 14 days:

did you receive a MOH Health Risk Warning SMS or a MOH Health Risk Alert SMS; OR
have you had close contactwith a COVID-19 person?

Yes
No

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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