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.

Health Screening Declaration Form

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Provide Visitor Information

Full Name *

Enter Your Full Name

Mobile No *

Provide your Mobile Number.

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

Meeting venue: *

Enter Meeting venue

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

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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