Student Health Self-Declaration Form (COVID-19)

Please complete this form according to the category you fall under:

Fields marked with * are mandatory.
Student ID*
Your 7 or 9 digits Student ID
Name*
Full name as per IC or Passport
Student Email*
e.g. 123456789@students.swinburne.edu.my
Program*
Privacy Notice

Swinburne University of Technology Sarawak Campus collects, uses and destroys personal information in accordance with the Personal Data Protection Act (PDPA) 2010.

For more information, please refer to the University’s Privacy Collection Notice at http://www.swinburne.edu.my/privacy/.
Status and Type of Vaccination and Current Health Condition

Please tick where applicable – information is required for easy reference for managing COVID-19 related cases.
Vaccination Status*

Double Dose and BoosterDouble Dose onlySingle DoseUnvaccinated
Type of Vaccination for Dose 1 and Dose 2*

SinovacPfizerAstra ZenecaOther
Type of Booster Vaccination*

SinovacPfizerAstra ZenecaOther
Current Health Condition*

Asymptomatic - Showing no symptomsSymptomatic - Showing symptoms
Complete the applicable category
Category*
Category 1: COVID-19 Patient
Student who has tested positive for COVID-19
Describe your current status*
Date infected*

DayMonthYear
Location infected*
Date last on campus*

DayMonthYear
Location visited on campus and close contact(s) when on campus*
Did you attend class on campus?*

YesNo
If yes, please provide us details of your class *
(Unit name, location, lecturer's name and classmates)
Self-quarantine Start Date*

MonthDayYear
Date
Self-quarantine End Date*

MonthDayYear
Date
Date been identified as PUI*

DayMonthYear
Self-quarantine Start Date*

DayMonthYear
Self-quarantine End Date*

DayMonthYear
Category 3: Close Contact

**Identified as close contact i.e. person who has been in contact with a confirmed COVID-19 patient (referred to as Layer 1) that may involve the following - as per definition by the Ministry of Health:

i) Shared space: People who live together; classmate in the same classroom with 1st generation (Layer 1)
ii) Close proximity: Face-to-face for more than 15 minutes, less than 1 meter distance, in an enclosed space with 1st generation (Layer 1)
iii) Long exposure: Not face-to-face but present in an air-conditioned room for more than 2 hours with 1st generation (Layer 1)
iv) Travelling together: Travelling in the same vehicle (1 or 2 seats apart) with 1st generation (Layer 1) for more than 15 minutes

** NO SUBMISSION of form is required for Asymptomatic Booster close contact if you are identified as being a close contact only after 3 days from last contact day to a positive case.
Describe relationship with person(s) with close contact (immediate family, relative, friend, colleague, others)*
Date of last contact with confirmed case*

DayMonthYear
Last date on campus*

MonthDayYear
Date
Who are your close contacts on campus in the last 5 days?*
Self-quarantine Start Date

DayMonthYear
Self-quarantine End Date

DayMonthYear
Emergency Contact Details
Emergency Contact Person*
Relationship*
Home / Mobile Number*
Address*
Should be Empty:

Status and Type of Vaccination and Current Health Condition

Complete the applicable category

Emergency Contact Details