| FORM VERSION | 2 |
|---|---|
| DATE | 01/10/2021 |
| TIME | 12:06:17 AM |
| IP ADDRESS | 183.171.106.237 |
| SELECT LANGUAGE | ENGLISH / MELAYU |
| WIDETECH EMPLOYEE ? | NO / TIDAK |
| VISITOR NATIONALITY | MALAYSIAN / MALAYSIA |
| IC NUMBER | 891110075226 |
| VISITOR NAME | MOHD FIRDAUS |
| 1. ARE YOU EXHIBITING 2 OR MORE SYMPTOMS AS LISTED BELOW ? | NO / TIDAK |
| 2. BESIDES THE ABOVE, ARE YOU EXHIBITING ANY OF THE SYMPTOMS LISTED BELOW ? | NO / TIDAK |
| 3. HAVE YOU ATTENDED ANY EVENT / AREAS ASSOCIATED WITH KNOWN COVID-19 CLUSTER ? | NO / TIDAK |
| 4. HAVE YOU TRAVELLED TO ANY COUNTRY OUTSIDE MALAYSIA WITHIN 14 DAYS BEFORE ONSET OF SYMPTOMS ? | NO / TIDAK |
| 5. HAVE YOU HAD CLOSE CONTACT TO CONFIRMED OF SUSPECTED CASE OF COVID-19 WITHIN 14 DAYS BEFORE ONSET OF ILLNESS ? | NO / TIDAK |
| 6. ARE YOU A MOH COVID-19 VOLUNTEER IN THE LAST 14 DAYS ? / | NO / TIDAK |