Name *

First Name

Last Name

Please select where appropriate: *

Crew

Cast

Location Owner

Vendor

Other

Have you travelled to or fro any countries within the last 28 days? *

Yes

No

Are you currently serving a Quarantine Order (QO), Leave of Absence (LOA), or Stay-at-Home Notice (SHN)? *

Yes

No

Within the last 28 days, have you had contact with a COVID-19 confirmed or suspect case, or a person issued with a Quarantine Order (QO) / Leave of Absence (LOA) / Stay-Home Notice (SHN)? *

Yes

No

Within the last 28 days, have you had contact with a member in the household who is unwell? *

Yes

No

Are you feeling unwell or do you have any symptoms (such as fever, cough, muscle ache, joint pain, headaches, sore throat, runny nose, shortness of breath, change in smell, change in taste, diarrhoea)? *

Yes

No

Consent and Acknowledgement *

By submitting this form, I confirm that I have read and understood its contents and have responded truthfully.

I further consent to the collection of my personal data and understand that all personal information collected will only be used for the purposes of contact tracing where necessary and is protected under the Personal Data Protection Act 2012 (PDPA).