Visitor's Health Declaration

Name of ERGO Staff you are visiting *

Your Date of Visiting *

Your Name as per NRIC/FIN/Passport *

Your Last 4 Digit NRIC/FIN/Passport *

Your Mobile Number *

Have you OR any of your household member returned to Singapore from overseas within the last 14 days? *

Have your OR any of your household members had contact with any cases of COVID-19? *

Do you have a household member issued with a Home Quarantine Order, Stay Home Notice or company/school-imposed Leave of Absence? *

Are you having fever? *
What is your temperature as measured by ERGO’s staff?*

Are you having breathlessness? *
Are you having cough? *
Are you having sore throat? *

Please provide information of Country/City Traveled/Transit in the last 3 weeks. *

(1) Country/City Traveled/Transit *

(1) From

(1) To

(2) Country/City Traveled/Transit

(2) From

(2) To

(3) Country/City Traveled/Transit

(3) From

(3) To

(4) Country/City Traveled/Transit

(4) From

(4) To

(5) Country/City Traveled/Transit

(5) From

(5) To