Health Declaration Form: Borang Pengisytiharan Kesihatan
Health Declaration Form: Borang Pengisytiharan Kesihatan
Health Declaration Form: Borang Pengisytiharan Kesihatan
KESIHATAN /
HEALTH DECLARATION FORM
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:………………………………………………………………………….
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.