Appendix 1

Ministry of Health Malaysia
HEALTH DECLARATION FORM
FOR PASSENGERS ON BOARD

Ladies and Gentlemen,
Welcome to Malaysia.
Malaysia is taking all the necessary precautionary measures against the spread of
COVID-19 infection into our country.
If you are coming from oversea/abroad, you are kindly requested to declare your healthstatus on the overleaf of this card as required under Section 12(1) of the Prevention andControl of Infectious Diseases Act 1988 [Act 342]. Any person who contravenes thissection, commits an offence (Section 12(3)).
The Ministry of Health Malaysia values your sincere cooperation in this matter.
Thank You.

Director General of Health
Ministry of Health Malaysia

Disease Control Division, Ministry of Health Malaysia,Level 3, 4, 6, Block E10, Federal Government Administration Centre,Parcel E, 62590 Putrajaya
Tel: 03-8000 8000 Fax no: 03-8888 0643
PUBLIC HEALTH COVID-19 HEALTH DECLARATION FORM

All person entering Malaysia shall complete all the information required in this Form
PART A(General)

1. Full name: ……………………………………………………………………………….
(Use block letters)

2. Gender:MaleFemale

3. Age (year/month): ………………………………………………………………………
4. Passport Number: …………………………………………………………..…………..
5. Nationality: …………………………………………………………………….…………
6. Identity Card No:…………………………………………………………………….......
7. Mode of Transport:

AirSeaLand

8. Flight No./Vehicle Registration No./Name of Ship/Name of Train:………………………………………………………………………………………..............

9. Seat No. (if applicable): ……………………………………………………………….
10. Last Place of Embarkation: …………………………………………………………...
11. Address in Malaysia: …………………………………………………………………..
………………………………………………………………………………………….........

12. Telephone No.
House: ...............................
Mobile:...............................

Office:...............................

PART B
COVID-19

1. Have you travelled overseas the past 14 days?
Yes

No

2. Date of departure: …………………………………

Country: ………………………..........

3. Have you had any of the following symptoms over the past 14 days? Please tick if yes
FeverCough
Difficulty in breathing
Sore throat
Sudden loss of sense of taste or smell
Other symptoms (please specify):…………………………………………
Have you been in 1close contact with person suspected to have COVID-19?
YesNo

If the answer is yes to either of the question above, please report to the Health Screening Area.
4.

Please indicate all countries and cities that you have visited or transited through in the last 14
days (including airport, ports and border crossing), providing the dates of the visit. List themost recent countries first.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________

1Definition close contact :••••Health care associated exposure, including providing direct care for COVID-19 patients, working with healthcare workers infected with COVID-19, visiting patients or staying in the same close environment of aCOVID-19 patient.
Working together in close proximity or sharing the same classroom environment with a COVID-19 patient
Traveling together with COVID-19 patient in any kind of conveyance
Living in the same household as a COVID-19 patient

Signature:…………………………
Date:…………………………