[ADDITIONAL FORM IF NECESSARY]

HEALTH DECLARATION FORM [TRAVELLING RECORD]

All person entering Malaysia shall finish all the information required in this Form

(General)

1. Full name: ……………………………………………………………………………….

(Use block letters)

2. Gender: Male Female

3. Age (year/month): ………………………………………………………………………

4. Passport Number: …………………………………………………………..…………..

5. Nationality: …………………………………………………………………….…………

6. Identity Card No:…………………………………………………………………….......

7. Mode of Transport: Air Sea Land

8. Flight No./Vehicle Registration No./Name of Ship/Name of Train:

………………………………………………………………………………………..............

9. Seat No. (if applicable): ……………………………………………………………….

10. Last Place of Embarkation:

…………………………………………………………... 11. Address in Malaysia:

…………………………………………………………………..

………………………………………………………………………………………….........

12. Telephone No.

House: ............................... Office:...............................

Mobile:...............................
 HEALTH DECLARATION FORM
[YOUR COMPANY NAME]
COVID-19

1. Have you been to any area or countries of COVID-19 as indicated by WHO or travel
interstate (from ONE state to another) over the past 14 days? Please tick if yes

Yes □ No □

2. Date of departure from the said country/ state: ……………………………………..........

3. Have you had any of the following symptoms over the past 14 days? Please tick if
yes Fever
Cough
Difficulty in breathing
Sore throat
Other symptoms (please specify) :
…………………………………………

Have you been in 1close contact with person suspected, infected and
diagnosed with COVID-19? Yes □ No □

[IMPORTANT] If the answer is yes to either of the question above, please

report to the Health Screening Area/ Kementerian Kesihatan Malaysia/
Klinik Kesihatan/ Hospital Kerajaan

1
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 COVID- 19 patient
 Traveling together with COVID-19 patient in any kind of conveyance
 Living in the same household as a COVID-19 patient

I (Name) ……………………………………………….., I/C or Passport: ……………………….

Hereby admit and acknowledge that the information I have given is accurate and complete.
I am aware that company can take legal action against me if the information given found to
be false and inccorect.

Signature:…………………………
Phone :…………………………
Date :…………………………
[YOUR COMPANY NAME/ DATE]
 HEALTH ALERT CARD - 2019 NOVEL CORONAVIRUS (2019-nCoV)

 Keep this reminder for your reference while your are in working premise.

 Monitor your body temperature and look out for fever, symptom of cough and
difficulty in breathing

 If symptom worsen and you are not feeling well, seek medical treatment at the
nearest healthcare facility IMMEDIATELY.

Kindly practice the following:

 Cover your mouth and nose using tissue whenever you cough or sneeze.
Throw the tissue in the trash after you use it;

 Wash your hand with soap and water or use hand sanitizer regularly;

 Always follow cough etiquette;

 Use face mask whenever being in public or close contact with people;

 Always maintain good personal hygiene and cleanliness.

[Adopted from Ministry of Health Malaysia]