| FORM VERSION | 1.0 |
|---|---|
| DATE | 04/09/2021 |
| TIME | 11:00:28 AM |
| IP ADDRESS | 183.78.80.25 |
| WIDETECH EMPLOYEE ? | NO / TIDAK |
| VISITOR NATIONALITY | NON-MALAYSIAN / BUKAN WARGANEGARA |
| PASSPORT NUMBER | C4046356 |
| VISITOR NAME | MARLINA NAINGGOLAN |
| 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 |