Heal From Home - Health Declaration Form

Health Declaration Form

To facilitate contact tracing purposes and comply with Government Regulations, we seek your kind assistance in filling up the following declaration form.

Kindly note that this data will only be used for purposes of contact tracing and other response measures during the outbreak of Covid-19.

Date

Name

NIRC/FIN/Passport

Contact Number

Do you have a fever, cough, shortness of breath, blocked or runny nose, sore throat or difficulty smelling? *

Have you had close contact with someone with COVID-19 in the last 14 days?*

Have you travelled outside of Singapore in the last 14 days or returned from UK, India, or South Africa in the past 21 days?*

Are you staying in a dormitory? (for Work Permit Holders)*

Are you working in occupations or environment with risk of exposure to COVID-19 cases? Eg. Healthcare, Dormitory, Isolation/ Quarantine/ Community Care facilities or Ambulance/ dedicated patient transport etc*

Have you received a 'Health Risk Warning' (HRW) SMS in the last 14 days?*

Have you received a 'Health Risk Alert' (HRA) SMS in the last 14 days?*

Additional Information

I confirm that I have read and understood the health declaration questions, and have answered them accurately to the best of my knowledge. If any of my answers changes prior to my session, I understand that I will have to update the company accordingly.