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DECLARATION FORM FOR EMPLOYEES RETURNING FROM TRAVEL OUTSIDE SAUDI ARABIA

SECTION A: To be filled by Employee

I, ………………………………………………….., declare that the information below are correct, and I will not resume to work till I

receive a clearance Form from the Infection Prevention and Control Department.

Badge No:_________________________________________________________________________________

MRN:_______________________________________________________________________________________

MNGHA Region: __________________________________________________________________________

Job:_________________________________________________________________________________________

Work location:____________________________________________________________________________

Email:_____________________________________________________________________________________

Mobile number: _____________________________ Pager:_____________________________________

Date of arrival: _____________________________ Airline & Flight Number:_________________

Coming from: _____________ Direct: Yes No, if No which Country:______________

Epidemiological link

1.

Travel to China, Iran, South Korea, Japan, Singapore, France, Italy , Germany

,India, Malaysia, Lebanon, Pakistan , Azerbaijan , Afghanistan, Iraq , Egypt,

Hong Kong and Algeria within the last 14 days

Yes No

2 Visit any other country within the last 14 days

Which country?: ___________________________ Yes No

3 Contact with suspected case of COVID-19? Yes No

4 Contact with confirmed case of COVID-19? Yes No

Clinical condition

6 Shortness of Breath Yes No

7 Cough Yes No

8 Sore throat and/or runny nose Yes No

9 Fever Yes No

10 Others:________________________________________________ Yes No

IMPORTANT: Complete the form and EMAIL it back to the Infection Prevention and Control Department in your region. IP&C will

contact you with instructions for clearance to resume work. Be alert with your mobile or your NGHA email for any communication

from IP&C. If any symptom/s develop after 14 days, inform your supervisor and contact IP&C.

*please send this declaration form to:

Riyadh: ipc_ehohs@ngha.med.sa Jeddah: ifc@ngha.med.sa Dammam: infpncdd@ngha.med.sa Al-Ahsa: ipc2@ngha.med.sa Madinah: Icd_pmbah@ngha.med.sa

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Section B: To be filled by Assessing Staff

Employee MRN: __________________________________

Date of completing this form: _____________________

Epidemiological Link: Yes No

Clinical Signs or Symptoms: Yes No

Work Restrictions: Yes Duration: __________ No

Close contacts (if any epidemiological link or symptomatic):_______________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Patient cleared: Yes No

Screening performed by: __________________________________________________________________

Comments: _________________________________________________________________________________

Date: ________________ Badge:_______________

Signature: __________________________

To employee’s supervisor/director:

Date: ________________

Badge: ______________

Supervisor/Director Name: _________________________________

Signature: _________________________

NOTE: Symptomatic staff will be directed to ACC Flu Clinic during working house, or to ER Flu Clinic after working hours or

weekends. Ensure staff is aware of the need to perform frequent hand hygiene and wear surgical mask.