SELF DECLARATION FORM

Self-Declaration Form for Resuming Workplace Post lifting of lockdown

Name: ________________________________ Date: ________

Ticket No: _____________________________

Dept: _________________________________

Contact No: ____________________________

Emergency Contact No: _______________________________

Please fill the table below:

History Yes (Details) No

Have you come in contact with any Covid affected person
in last 14 days?
Have you visited any health facility/ hospital in last one
month?
Have you or someone in your family/ friends visited any
other Country/ City by air/ road/ local public transport/
taxi in last one month?
Have you come in close contact with someone with cough,
cold, fever, and shortness of breath in last 14 days?
Did you/ close family member participate in any meeting/
gathering where more than 15 people attended in the past
two weeks?

Are you currently facing any symptoms described below?

Symptoms Yes No
Cough
Cold
Fever
Sore throat
Body ache
Headache
Weakness
Breathlessness
Fatigue

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SELF DECLARATION FORM

Note: If you have selected ‘Yes’ for any of the above options, please contact your HR before
coming to workplace.

I will strictly adhere with all guidelines as precautionary measures shared by the organization.
In case any of these symptoms, I take responsibility to visit the doctor and to keep HR/
Manager informed about the same.

I hereby confirm the above-mentioned details are correct.

Regards,

Employee Name