Self Declaration System

Full Name
Submission Date
NRIC or Passport
Phone No
Nationality
Business Unit
Cluster
Email Address
Have you travelled to / resided in a foreign country within 14 days before the onset of illness?
You have answered "Yes" in the previous question, please indicate visited country	-
You have answered "Yes" in the previous question, please indicate your date of arrival to Malaysia	-
Have you been in close contact with a confirmed case of COVID-19 in the last 14 days?
Have you been in close contact with a person that has travelled to / resided in a foreign country in the past 14 days?
Have you been in close contact with someone who is under the ‘Home Quarantine Order’ OR someone suspected of COVID-19 OR someone who has attended the ‘Ijtimak Tabligh’ at Masjid Seri Petaling in the past 14 days OR attended an event associated with known COVID-19 outbreak?
Are you currently under the ‘Home Surveillance Order’ OR from ‘Enhanced Movement Control Order (EMCO)?
You have answered "Yes" in the previous question, please indicate the area	-
Please indicate which of the following symptoms you have
Emergency Contact Name
Emergency Contact Number
Emergency Contact Relationship