Travel and Health Declaration

For more details, please visit www.mom.gov.sg/wuhanvirus

*This declaration will be used by employers for purposes of obtaining the travel history of employees. The information should not be used for any other purposes.

Name of Employee *

Department *

Sales

Product Engineer

Process

Operations

G&A

Finance

Procurement

Nationality *

1. Did you travel to overseas recently?

Yes (If yes, please fill in 1.a. and 1.b.)

1.a. Which countries have you visited?

1.b. When did you last return to Singapore?

2. Have you had close contact* with a person diagnosed as a probable case of COVID-19? cared for, lived with or had direct contact from a suspect case?

Yes

3. Are you feeling unwell with mild flu-like symptoms, coughing, runny nose, sneezing or breathlessness? *

Yes

4. Over the past 7 days has your temperature been above 37.5 °C (99.5 °F)? *

Yes