KSM Health Tracking System

Personal Information

Dear Sir / Madam,
To prevent the spread of Covid-19 in our community and reduce the risk of exposure to any person, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this premise. Thank you for your time.

Name*

NRIC/Passport No.*

HP No.*

Gender*

Male

Female

Living Area*

Vistitor Type*

Customer

Supplier

Rider

Staff

Others

Company*

Purpose*

#	Health Information
1	Have you travelled to any Red Zone area of COVID-19 within last 14 days?	Yes No
2	Have you been in close contact with family, friends or individuals who have travelled to Red Zone area of COVID-19 within the last 14 days?	Yes No
3	Have you attended or come in contact with someone who attended an event or went to a place associated with COVID19 within last 14 days?	Yes No
4	Have you been in close contact with suspected (PUI)/confirmed case for COVID19 within the last 14 days?	Yes No
5	Do you have following conditions/symptoms within the last 14 days? Please tick if Yes Fever Cough Sore throat Shortness of breath Others

Body Temperature*

Wearing mask?

Yes

Declaration

*I agree that the above information provided is, to the best of my knowledge, complete and true.

*I agree to the collection, use and disclosure of above information for the purposes of a precautionary measure against COVID19 in the company's premises.

*I agree to abide to the COVID19 guideline issued by the company including wearing face mask at all times, frequent washing/sanitizing hands, daily temperature check, social distancing measures & etc

*I agree to inform my Head of Department (H.O.D.) if I feel sick or have shown symptoms of COVID19.