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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? * ---YesNo
Have your OR any of your household members had contact with any cases of COVID-19? * ---YesNo
Do you have a household member issued with a Home Quarantine Order, Stay Home Notice or company/school-imposed Leave of Absence? * ---YesNo
Are you having fever? * ---YesNo Are you having breathlessness? * ---YesNo Are you having cough? * ---YesNo Are you having sore throat? * ---YesNo
Please provide information of Country/City Traveled/Transit in the last 3 weeks. *