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Health Declaration Form: Borang Pengisytiharan Kesihatan

This document is a health declaration form asking individuals about their COVID-19 status and risk factors. It asks if they are experiencing symptoms, have previously tested positive, had close contact with someone who tested positive, traveled internationally in the last 14 days, or are currently under home quarantine. The individual must declare that the information provided is true and correct, and that legal action can be taken if any information is false. It also defines what is considered a close contact.

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hasan mamat
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116 views1 page

Health Declaration Form: Borang Pengisytiharan Kesihatan

This document is a health declaration form asking individuals about their COVID-19 status and risk factors. It asks if they are experiencing symptoms, have previously tested positive, had close contact with someone who tested positive, traveled internationally in the last 14 days, or are currently under home quarantine. The individual must declare that the information provided is true and correct, and that legal action can be taken if any information is false. It also defines what is considered a close contact.

Uploaded by

hasan mamat
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
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BORANG PENGISYTIHARAN

KESIHATAN /
HEALTH DECLARATION FORM

1. Adakah anda mengalami gejala-gejala berikut?


Do you have these symptoms?
a) Demam / Fever Ya / Yes Tidak / No
b) Batuk / Cough Ya / Yes Tidak / No
c) Selsema / Flu Ya / Yes Tidak / No
d) Sesak nafas / Difficulty in breathing Ya / Yes Tidak / No

2. Adakah anda pernah disahkan positif COVID-19? Ya / Yes Tidak / No


Have you being declared as a positive COVID-19?

3. Adakah anda mempunyai kontak rapat dengan


mereka yang disahkan POSITIF COVID-19? Ya / Yes Tidak / No
Do you have history of close contact with anyone who
has been Diagnosed as COVID19 POSITIVE?

4. Adakah anda mempunyai sejarah perjalanan ke luar Ya /Yes Tidak / No


negara dalam tempoh 14 hari yang lepas?
Do you have history of travelling to overseas for the last 14
days?

5. Adakah anda sedang menjalani perintah kawalan


kuarantin di rumah yang diarahkan oleh Kementerian Ya / Yes Tidak / No
Kesihatan
Malaysia?
Are you currently under strict home quarantine as
instructed by Ministry of Health Malaysia?

Saya mengesahkan bahawa semua maklumat yang diberikan adalah betul dan tepat.
Tindakan boleh dikenakan jika maklumat yang diberikan adalah palsu.

I hereby declare that all the information given in this form is true and correct. Action can be
taken if the information provided is false.

Nama / Name :………………………………………………………………………………………………………

No. KP / NRIC:……………………………………….................No. Tel:………………………………………….

IPT:……………………………………………………................Tarikh / Date:.................................................

T/Tangan / Signature :
Definition close contact :
• Health care associated exposure, including providing direct care for COVID-19 patients, working with
health care workers infected with COVID-19, visiting patients or staying in the same close environment
of a COVID-19 patient.
• Working together in close proximity or sharing the same classroom environment with a with COVID19
patient
• Traveling together with COVID-19 patient in any kind of conveyance
• Living in the same household as a COVID-19 patient.

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