Event Participation Registration

In 2019, Singhs and Kaurs Malaysia Society aims to be part of a national entity to engage the Malaysian Indian community as one. There is no distinction between the community. #NoUNorUs,WeR1#; one community that strives to be Community Sewadars.

SKMS aims to promote the wellbeing of our family’s function and intergenerational gathering over joined community events, or any other form of gatherings to promote interactive session over issues pertaining to spiritual, physical, social, health, mental wellbeing and education. Therefore, for the year 2019, we will dedicate our efforts through #MyIndian1CommunityFair# to fulfil the following:

  • Family & Food “A Family Celebration”: Promote healthy eating;
  • Hakuna Matata: Promoting destress mechanism via the use of art & music.
  • Baby Boomers: The aim of this component is to integrate our elders into our community activities.
  • Family my Pillar: A honeycomb of love, respect, honour and bonding of the community strengthens a family relationship and family health. There is a need to emphasize healthy intergenerational relationships within family members.
  • Z Generation: An entertaining section which integrates activities aimed for a child, adolescence and youth-based activities. It is hoped that this fair promotes health and wellness approach that starts with our young ones.
EventSJK(T)
Kampung Pandan		SJK(T)
Kampung Pandan		GS Kg PandanSJK(T) 
Kampung Pandan		GS Kg Pandan
Date3rd Aug 18th Aug 24th Aug 22nd Sept 12th Oct 
Time8am- 1pm8am- 1pm8am- 4pm8am-4pm8am-1pm

For further information visit our website: http://singhskaursmy.org

Please fill in the registration form below to register your participation in the event.

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1 `DEMOGRAPHIC
2 Health screening
3 tobbaco use
4 Tobbaco USE
5 ALCoHOL COnSUMPTION
6 ALCOHOL CONSUMPTION
7 CONSENT
Demographic Information
FamilyID(optional if any)
Full Name
NRIC
Mobile Number
Gender
Age
Birth Date
Number of years spent in school?in year
What is the highest level of education you have completed?
Race Category
Other Race
Address
0 /
Marital Status
Other Marital Status
How many people older than 18 years, including yourself, live in your household?Number of people
Which income group do you belong to?
Which of the following best describes your main work status over the past 12 months?
If you are not employed, who in your family is employed?
What is the employment, of the family member who is employed?
What days will you attend?
How many members will join the event with you?
Health Screening Information
Have you ever participated in health screening?
If yes, When?

If you ever been tested for the following?

HIV
Hepatitis
If yes, which of the following?
If yes, for the above, pls advice if you have you receive treatment for hepatitis?
0 /
Have you ever participated in screening for sexual infected diseases?
If yes, which one?
0 /
If yes, for the above, please advice if you have you receive treatment?
0 /
Tobbaco Use
Do you currently smoke any tobacco products, such as cigarettes, cigars, e-cigarettes, vape or pipes/shisha/hookah?
Do you currently smoke tobacco products daily?
How old were you when you first started smoking?write 77 if don't remember
Do you remember how long ago it was?write 77 if don't remember

On average, how many of the following products do you smoke each day/week?

Manufactured cigaretteswrite 7777 if don't know
Hand-rolled cigaretteswrite 7777 if don't know
Pipes full of tobaccowrite 7777 if don't know
Cigars, cheroots, cigarilloswrite 7777 if don't know
Number of Shisha sessionswrite 7777 if don't know
Other tobacco productother tobacco product
Other tobacco product namePlease specify
During the past 12 months, have you tried to stop smoking?
During any visit to a doctor or other health worker in the past 12 months, were you advised to quit smoking tobacco?
In the past, did you ever smoke any tobacco products?
In the past, did you ever smoke daily?
How old were you when you stopped smoking?
How long ago did you stop smoking?write 77 if don't know
Do you currently use any smokeless tobacco products such as [snuff, chewing tobacco, betel]?
Do you currently use smokeless tobacco products daily?

On average, how many times a day/week do you use ….

Snuff, by mouthwrite 7777 if don't know
Snuff, by nosewrite 7777 if don't know
Chewing tobaccowrite 7777 if don't know
Betel, quidwrite 7777 if don't know
Other smokeless product
Other smokeless product namePlease specify
In the past, did you ever use smokeless tobacco products such as [snuff, chewing tobacco, or betel]?
In the past, did you ever use smokeless tobacco products such as [snuff, chewing tobacco, or betel] daily?
During the past 30 days, did someone smoke in your home?
During the past 30 days, did someone smoke in closed areas in your workplacein the building, in a work area or a specific office?
Alcohol Consumption
Have you ever consumed any alcohol such as beer, wine, spirits or [toddy]?
Have you consumed any alcohol within the past 12 months?
Have you stopped drinking due to health reasons, such as a negative impact on your health or on the advice of your doctor or other health worker?
During the past 12 months, how frequently have you had at least one standard alcoholic drink?
Have you consumed any alcohol within the past 30 days?
During the past 30 days, on how many occasions did you have at least one standard alcoholic drink?
During the past 30 days, when you drank alcohol, how many standard drinks on average did you have during one drinking occasion?
During the past 30 days, what was the largest number of standard drinks you had on a single occasion, counting all types of alcoholic drinks together?
During the past 30 days, how many times did you have six or more standard drinks in a single drinking occasion?
During each of the past 7 days, how many standard drinks did you have each day?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
During the past 7 days, did you consume any homebrewed alcohol, any alcohol brought over the border/from another country, any alcohol not intended for drinking or other untaxed alcohol?

On average,how many standard drinksof the following did you consume during the past 7 days?

Homebrewed spiritse.g. moonshine
Homebrewed beer or winee.g. beer, palm or fruit wine
Alcohol brought over the border/from another country
Alcohol not intended for drinkinge.g. alcohol-based medicines, perfumes, after shaves
Other untaxed alcohol in the country
During the past 12 months, how often have you found that you were not able to stop drinking once you had started?
During the past 12 months, how often have you failed to do what was normally expected from you because of drinking?
During the past 12 months, how often have you needed a first drink in the morning to get yourself going after a heavy drinking session?
During the past 12 months, have you had family problems or problems with your partner due to someone else's drinking?

Welcome to #MYIndian1CommunityFair. This fair aims to enhance Indian community health. We are offering health screening to improve care, health needs and health behaviours within urban and semi-urban localities in Malaysia. This is a collaborative activity between Singhs and Kaurs Malaysia Society and Researcher, Dr Sangeeta Kaur, Public Health Specialist from Perdana University Malaysia. 

All our volunteers at respective booths are trained to answers your queries pertaining to the services they offer. In addition, there are also experts available at the booth sites to answers any queries you may have pertaining to the research component at this fair. We will be happy to explain the research component to you.

Who can I talk to?

Why are we doing this research?

This is an automated process; thus, no signature is required. However, if you are keen to participate, you must provide consent by clicking on the “AGREE” button provided at the bottom of this page. To avoid technology glitches additional prompt message will appear to seek confirmation on your agreement to participate in the relevant services offered at respective booths.

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