kkbs

BORANG PENGISYTIHARAN DIRI
SELF-DECLARATION FORM




1. Adakah awda mempunyai tanda-tanda jangkitan influenza seperti berikut
1. Do you have any of the following influenza symptoms:



2. Senaraikan tempat-tempat / kota/ negara yang dilawati 14 hari kebelakangan
2. Please list the country / city you have travelled to in the last 14 days



3. Adakah awda atau keluarga terdekat awda terdedah dengan orang yang telah disahkan mengidap jangkitan Covid-19 dalam jangkamasa 14 hari kebelakangan? (Maksud Terdedah, berada dalam lingkungan 1 meter selama 30 minit)
3. Have you or an immediate family member come in close contact with a confirmed Covid-19 case in the last 14 days? ("close contace" means being at a distance of less than one metre fo more than 30 minutes



4. Dalam jangka masa 48 jam terakhir, adakah awda terdedah dengan:
4. In the last 48 hours from point of declaration, have you been in close contact with a:





5. Pengesahan Pengisytiharan
5. Confirmation of Declaration:




Sila cetak ke format pdf dan hantar kepada alamat email COVID19@kkbs.gov.bn
Please print to pdf format and send through email to COVID19@kkbs.gov.bn