Title: - Health Screening Form (for Customers) 20200610 E Author: 70K6843 Created Date: 6/10/2020 4:59:39 PM
Confidential-P HEALTH DECLARATION FORM (FOR HOME VISIT CUSTOMERS) Dear Sir/ Madam To prevent the spread of COVID-19 in our community and reduce the risk of exposure to our staff and customers, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in our community. Thank you for your time. Name Address: Product: (Pls tick) Aircon Television Contact Details Contact Number Service Job No: (if any) Fridge Washer Microwave/Oven Others ______________________ Self-declaration by Customer 1 If you have the following symptom(s), please tick the relevant box(es): Fever Dry cough Body aches Headaches Sore throat Runny nose Tiredness Shortness of breath Others ___________________ None of the above 2 Have you or any household member(s) had close contact with any persons who have been served with Quarantined Order, Leave of Absence, Stay Home Notice, warded for observation and testing for the coronavirus or confirmed cases in the last 14 days? Yes No 3 Have you or any household member(s) travelled to any countries in the past 14 days? Yes No If yes, please indicate the country(s)________________________ 4 Have you or any household member(s) been issued with a 5-day medical leave due to respiratory symptoms? Yes No 5* Do you have more than 10 members within your household? Yes No If yes, can you make arrangements to excuse 2 members outside your home during the time of visit? Yes No Footnote: If you have answered "Yes" to any of the above questions* and/or if you are unwell, please refrain from arranging a service appointment with us. We thank you for your kind understanding and we apologize for any inconveniences caused. Declaration: I declare and confirm that the given above is true and correct. ___________________________ Name and Signature __________________________ Date Panasonic Singapore (52940054E) 202 Bedok South Avenue 1 #02-02, Singapore 469332. Tel: 6270 0110 Website: http://www.panasonic.com.sgGPL Ghostscript 9.23