Health Declaration Sample
Back to Top

Health Declaration

Name (As in NRIC) *:
Phone Number *:
Declaration:
  1. I do not have a fever, cough, sore throat, runny nose and breathlessness.
  2. Neither my family members nor I have been in close contact with any influenza / pneumonia or patient infected with the new disease in the past 14 days.
  3. I have not travelled to the list of affected countries, Mainland China, Egypt, France, Germany, Hong Kong, India, Italy, Indonesia, Iran, Israel, Japan, Malaysia, Philippines, Republic of Korea, Spain, Thailand, United Kingdom, United States
  4. I have not been in contact with someone currently being issued a Quarantine Order, or Stay-Home Notice (SHN) in the last 14 days.
I declare the above information to be true.
INDEMNITY:
I will indemnify and keep indemnified, save and hold harmless, *** against all loses, claims, demands, actions, proceedings, damages, costs, expenses, including legal fees, and any other liability arising in any way from my entry into the ***.
I declare the above information to be true.
Reset Submit