Health Declaration Form

To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our staff and visitors, please complete the following screening questionnaire.

Name *

Type:

Yard *

Contact No *

Company

Temperature reading: ¹

^oC

If you have the following symptom(s), please tick the relevant box(es):

Fever/Chills

Cough

Difficulty Breathing

Sore Throat

Fatigue

Diarrhoea

Nausea

Loss Of Smell/Taste

* Required fields
¹ Required reading From HSE/Security Personnel

Self-declaration

1.	Have you, members of your family or household returned from outside of Sarawak or Malaysia in the past 14 days?	Yes No
2.	Have you, members of your family or household been to any of the Declared Red Zones in Malaysia in the past 14 days?	Yes No
3.	Have you, members of your family or household been to any of the declared a COVID-19 Infected Area in Miri in the past 14 days?	Yes No
4.	Have you, members of your family or household been in closed contact with any persons diagnosed with or suspected to be infected with COVID-19?	Yes No

For visitors answering "YES" to Question 1, 2, 3 & 4, you are temporarily restricted from entering Sarawak Slipways Sdn. Bhd. You are encourage to use collaboration tools instead of in-person/ on-site meetings as much as possible in this case.

	I hereby declare that to the best of my knowledge the information provided above is true and accurate and that I understand that any information provided here, if untrue, may contribute to the spread of COVID-19 that is dangerous to life, or cause harm or hurt to other persons.
	I further acknowledge that if the above information is untrue, I may be charged or punished or fined or both in the accordance to the law.