Self Declaration Form | Penang Automation Cluster Sdn Bhd

PAC COVID-19 EMPLOYEE SELF DECLARATION FORM
Employee Name	Employee Number
Visit Date
Tick if you have any of the following symptom: Fever (>37.5)Runny NoseHeadacheSore ThroatShortness of breathGeneral Feeling of being unwellNone of the above Others, please state
I declare that I DO NOT have the following experiences: 1.Close contact with a COVID-10 patient in the last 14 days 2.Travelled to oversea in the past 14 days 3.Attended any event or visited any area which was reported to have suspected or confirmed COVID-19 case in Malaysia 4.MOH COVID-19 volunteer in the last 14 days
Otherwise, please elaborate

I agree that the information above is accurate to the best of my knowledge. By signing this declaration, I hereby consent to the processing of my information set forth in this Self-Health Declaration Form by PAC for the purpose of prevention and control measures against COVID-19 including the disclosure of such information to the relevant government authorities, if required.

PAC COVID-19 VISITOR SELF DECLARATION FORM
Visitor Name	Company Name
PAC Host Name	Contact Number
Visit Date	Email

Have you travelled to oversea in the past 14 days?	YesNo
Have you attended an event or visited any area which was reported to have suspected or confirmed COVID-19 case in Malaysia?	YesNo
Are you a MOH COVID-19 volunteer in the last 14days?	YesNo
Tick if you have any of the following symptom: Fever (>37.5)Runny NoseHeadacheSore ThroatShortness of breathGeneral Feeling of being unwellNone of the above Others, please state
Have you had close contact with a COVID-19 patient in the last 14days?	YesNo