Declaration Form

Given the evolving situation resulting from COVID-19 (Coronavirus Disease 2019), we are taking measures to ensure the safety and well-being of our customers, visitors, staff and the community.

Please take a couple of minutes to complete this form. The information gathered will be useful for contact tracing should the need arise.

We advise those who are feeling unwell to rest at home. We seek the understanding and cooperation of our customers and members of the public as we work together to contain this situation.
Thank you!
Personal Info
Name*
First Last
Mobile No.*
Email*
I intend to go to*
Date of Visit*
DD slash MM slash YYYY
Declaration
Have you travelled to any of the countries listed under the Ministry of Health's (MOH) travel advisory within the last 14 days?*
E.g. Mainland China, France, Germany, Italy, Iran, South Korea, Spain, Japan, Switzerland, UK, and ASEAN countries (does not apply to land and sea crossings with Malaysia for Singaporeans and Malaysians)

See MOH's travel advisory here
- Yes
- No
Are you currently feeling unwell or having any respiratory symptoms such as fever, cough, runny nose, or sore throat etc.?*
- Yes
- No
Did you, in the past 14 days, come in contact with someone who is a confirmed/suspected COVID-19 case, OR is part of a COVID-19 cluster OR is issued with a Quarantine Order/Leave of Absence/Stay Home Notice?*
- Yes
- No
Are you currently serving Quarantine Order, Leave of Absence or Stay Home Notice?*
- Yes
- No
Declaration*
- I agree and declare that the information provided by me is accurate to the best of my knowledge
Phone
This field is for validation purposes and should be left unchanged.

Declaration Form

Personal Info

Declaration

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