INCEIF - HEALTH DECLARATION FORM FOR VISITORS

To prevent the spread of COVID-19 and reduce the risk of exposure to our stakeholders, we are conducting a simple screening questionnaire. Your cooperation is important to help us take precautionary measures to protect you and everyone in these premises.

Due to the rising number of cases in the country, external visitors are required to perform a self-test before being allowed entry. Kindly upload a screenshot/picture of your negative self-test in this form.

This form must be submitted one day in advance before the date of the intended appointment latest by 5.00 pm. Late submissions will not be entertained.

Health Screening Declaration Form

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Provide Visitor Information

Full Name *

Enter Your Full Name

Mobile No *

Provide your Mobile Number.

Company/Institution *

Enter name of your Company/Institution

NRIC/Passport/Co. No *

Provide either your NRIC or Passport or Co. No

Mode of transportation: *

Car Motorcycle Taxi / e-Hailing Service Public transportation

Plate Number: *

(Required for car / motorcycle only)

Email *

Enter Your Email

Date of visit: *

Time of visit: *

Name of host / officer-in-charge: *

Enter Name of host / officer-in-charge

Purpose of Appointment/Meeting: *

Enter purpose of the meeting/appointment. E.g:Meeting with Marketing Team

Health Declaration

In the last 14 days have you:		Yes	No
1	Returned from an outstation trip?
1	If ‘Yes’, please provide the name of place:
2	Attended any gatherings identified as clusters by MOH?
3	Been identified as a close contact to a confirmed Covid-19 case?
4	Any of your household identified as a close contact?
5	Are you currently experiencing any of the symptoms below:
	• Fever
	• Cough
	• Sore throat
	• Runny nose
	• Shortness of breath

Vaccination Status *

Please choose your Vaccination Status

Self-test Result: *

Please upload the screenshot of your test result here. In JPEG or PDF format.

CONFIRM AND SUBMIT

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Name:

Date:

By submitting this form I hereby agree that the International Centre for Education in Islamic Finance (INCEIF) may collect, obtain, store and process the personal data provided in this form for the purpose of conducting a health screening, and if required, for contact tracing purposes hereafter.

I understand that INCEIF may deny my entry to its campus based on the information provided above.

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