Name *

First Name

Last Name

Have you returned from China, Republic of Korea, Japan, Italy, Iran, France, Spain, Germany, Switzerland, United Kingdom, and ASEAN countries* in the past 14 days? *

yes

no

Do you have flu-like symptoms (e.g. fever, cough etc.)? *

yes

no

Did you, in the past 14 days, come in close contact with someone who (i) Is a confirmed COVID-19 case; OR (ii) Is part of a COVID-19 cluster? *

yes

no

Have you returned from the Middle East* in the past 14 days? *

*High Risk Middle Eastern Countries (for MERS-CoV) include: Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates & Yemen

yes

no

Did you come in contact with someone who has returned from Middle East and he/she is not feeling well in the past 14 days? *

yes

no