Form - XMUM Campus Access

Visitors/Suppliers/Contractors E-Health Declaration

Xiamen University Malaysia (XMUM) is taking all the necessary precautionary measures against the spread of COVID-19 Infection into our campus to protect our students, employee as well as visitors. It is mandatory for you to register and declare your health condition as in this form.

Your understanding and cooperation will be highly appreciated.

Full Name as per NRIC or Passport

NRIC Number or Passport Number

Nationality

Date of Visit

Car Plate Number

Company / School / College / University Name

Mobile Number (Sample: 60123456789)

Purpose of Visit

XMUM Staff Name

Have you been to any area or countries of COVID-19 as indicated by WHO over the past 14 days?

Yes

Have you been in *close contact people being infected, suspected or diagnosed with COVID-19?

Yes

Have you been to East Malaysia (Sabah and Sarawak) or have close contact with someone from East Malaysia over the past 14 days?

Yes

Have you had any of the following symptoms over the past 14 days? Please tick if yes.

Fever

Sore throat

Cough

Difficulty in breathing

Flu

Loss sense of smell or taste

No Symptoms

If you have answered 'Yes' to any of the questions above, you will be denied entry to the campus.

By submitting I hereby confirm that the information I have given above is true. I agree to the collection, use and disclosure of my information above by Xiamen University Malaysia for the purpose of precautionary measure against COVID-19.

*Defination of close contact :

Health care associated exposure, including providing direct care for COVID-19 patients, working with health care workers infected with COVID-19, visiting patients or staying in the same close environment of a COVID-19 patient.
Working together in close proximity or sharing the same classroom environment with a with COVID-19 patient.
Traveling together with COVID-19 patient in any kind of conveyance.
Living in the same household as a COVID-19 patient.