Covid 19 Declaration Form

As part of public health risk preventive measures, we seek your cooperation to provide the following information on this Declaration Form for the safety of all occupants/visitors in the building and for contact tracing purposes. Please be informed that your Personal Data will be processed according to Hong Leong Bank/Hong Leong Islamic Bank’s (Collectively referred to as the “Bank”) Privacy Notice which is available upon request or from the Bank’s website. Thank you for your time and understanding.

* Name (as per NRIC/Passport)

* Branch Code

* Contact No (mobile)

Contact No (mobile number without spaces e.g. 0123456789)

Have you travelled overseas in the last 21 days?

Yes

If Yes, please provide the details:

Country/City

Period of visit:

From

To

Were you quarantined upon your return to Malaysia?

Yes

Have you been in close contact** with a Person Under Investigation (PUI) or a confirmed Coronavirus (Covid-19) patient in the last 21 days?

Yes

If Yes, please provide the details:

Do you have any of the following symptoms (fever, cough, shortness of breath, running nose, sore throat)?

Yes

Your temperature reading

Reading 1

Reading 2 (if necessary)

I declare that the information provided in this form is true and accurate. I consent to the Bank’s collection, use and disclosure of my Personal Data according to the Bank’s Privacy Notice and for the safety of the occupants/ visitors in the building, including for contact tracing purposes:

Submit

**Definition of direct/close contact (guided University Hospital, unless further advised by KKM):

living in the same household / same group (sleep / eat together)

Face-to-face meeting for more than 15 minutes within distance of less than 1 meter in closed space

Non face-to-face but together in an air conditioned room for more than 2 hours

In the same vehicle for more than 2 hours

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Reading 2 (if necessary)

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Reading 2 (if necessary)

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