Homestay Health Declaration Form (Tourist Use)
Personal Information
Full Name
Passport/ID Number
Nationality
Date of Birth
Gender
Male
Female
Other
Current Address
Phone Number
Email Address
Check-in Date
Check-out Date
Travel History (Last 14 Days)
Countries/Regions Visited
Health Declaration
Do you have any of the following symptoms?
Fever
Cough
Sore Throat
Shortness of Breath
None
Have you had contact with a confirmed COVID-19 case?
Yes
No
Comments / Other Information
Declaration
I hereby declare that the above information is true and correct to the best of my knowledge.