Self-Declaration Form

Dear Visitor,

Given the evolving situation in COVID-19, we are taking the necessary measures to ensure the safety and well-being of
our visitors, staff and their families. As such, we request that you take a couple of minutes to fill in this form. The
information gathered will be useful for contact tracing, should the need arise.

Section 1: Personnel Information

Details

1. Name & Organization

Rajkumar Jangra Horizon
2. Email jangra_r@yahoo.com

3. Name of N-KOM Staff-in-charge of your visit Tejus Subeqi /Mr. Muthu (+974 3339 5315 )

Section 2: Questions for Visitors, Contractors, Service Engineer, Client and Vendor
Questions Y/N Details

4. Have you visited other infected countries within the last 2 weeks? Have you been
quarantined or isolated for 7 or 10 days? N

5. Please declare countries travelled during the last one month ( if vessel, last Port
Call and it’s activity) and date of last crew change? India

6. Do you or any of your family members or roommates have flu-like symptoms

(e.g. fever, cough etc.)? N

7. Do any of your close contacts have flu-like symptoms or COVID19 positive case?
N

8. Do you have any housemate/roommate in your accommodation? If yes, is

he/she under home isolation or home quarantine due to COVID19 Symptoms N
or Post Travel under home quarantine?

9. Do you have any reported cases of coronavirus from your Residence or Camp
and when? Are you one of the close contacts? N

10. Do you have one of these symptoms fever, colds, cough, throat pain, body
weakness, loose motion now? N

11. Did you attend a COVID-19 Swab Test and When? If Yes, was it for a purpose of RTPCR : 05 Jul 2022 :Results :Negative
Offshore activity, Close Contact or Suspected Case? And share the result Y RAT : 11 Jul 2022: Results :Negative
All for travelling purpose
12. Did you have COVID19 Vaccine? When was the 2nd dose Taken? (Specify the 2nd Dose: 31 July 2021, Covaxine
COVID19 Vaccine Brand) 3rd Dose: 13 May 2022, Covaxine

Note: A scanned copy of this form shall be sent to HSSE Health representative prior to departure – minajoy.r@nkom.com.qa, and the visitor or personnel shall bring the original form
and shall be validated at the NKOM Security Gate.

Signature/ Date

Page 1 of 1
 Certificate for COVID-19 Vaccination
Issued in India by Ministry of Health & Family Welfare, Govt. of India
Certificate ID 71336583638

Beneficiary Details
Beneficiary Name / लाभाथ चे नाव Rajkumar Jangra

Age / वय 49

Gender / लग Male

ID Verified / ओळखप Passport # Z4352433

Unique Health ID (UHID) 62-5234-7017-5205

Beneficiary Reference ID 52424645372310

Vaccination Status / लसीकरण ती Fully Vaccinated (2 Doses) and a Precaution Dose

Vaccination Details
Vaccine Name / लसीचे नाव COVAXIN

Vaccine Type / लस कार COVID-19 vaccine, inactivated virus

Manufacturer / उ पादक Bharat Biotech, India

Dose Number / डोस मांक 1/2 2/2 Precaution dose

Date of Dose / डोसची तारीख 02 Jul 2021 30 Jul 2021 13 May 2022

Batch Number / बॅच मांक 37H21002A 37I21015A 37H21015A

Vaccinated By / यां ा ार लसीकरण Vishakha Bhosale

Vaccination At / लसीकरणाचे ळ NMMCP Apollo Hospital, Thane,

Maharashtra

औषध सु ा आ ण श सु ा
Together, India will defeat
COVID-19”
- पंत धान ी. नर मोदी

In case of any adverse events, kindly contact the nearest Public Health Center/
Healthcare Worker/District Immunization Officer/State Helpline No. 1075

कोणतेही तकूल प रणाम आढळू न आ यास कृपया जवळचे सावज नक आरो य क / आरो यसेवा
कमचारी/ ज हा लसीकरण अ धकारी/ रा य ह पलाइन मांक १०७५ वर संपक साधा.

This certificate can be verified by scanning the QR code at

http://verify.cowin.gov.in
 LABORATORY REPORT

Name : Mr. JANGRA RAJKUMAR KHUSHIRAM Sex/Age : Male / 59 Years Case ID : 20701000706
Ref. By : Dis. At : DOB 26-07-1972Q Pt. ID : 2152341
Bill. Loc. : Pt. Loc :
Reg Date and Time : 05-Jul-2022 12:49 Sample Type : Nasopharyngeal + Mobile No. : 9820307892
Oropharyngeal Swab
Sample Date and Time : 05-Jul-2022 12:49 Sample Coll. By : Ref Id1 : TRAVEL
Report Date and Time : 05-Jul-2022 17:48 Acc. Remarks Ref Id2 : Z4352433

TEST RESULTS UNIT BIOLOGICAL REF RANGE REMARKS

Genomics
COVID19 Qualitative by Real time PCR (ICMR No. SUPRA001f)

COVID19 Interpretation NEGATIVE

Real time PCR

N gene (Ct) Negative

Orf gene (Ct) Negative

Test: Qualitative test of COVID19 RNA by standard procedure on rt Real-time PCR.
Methodology: Reverse transcriptase Real-time Polymerase chain reaction.
Interpretations:
20701000706-Mr. JANGRA RAJKUMAR KHUSHIRAM-59 Years-Male

Cycle threshold (Ct value) Value ranges from 15-40 cycle. Lower the Ct value higher is the viral load (Inversely proportional).
Kindly correlate with the clinical presentation and findings.
According to latest CDC guidelines, Ct cutoff of more than 33 is not considered as infective as it is extremely
difficult to detect any live virus in a sample above the threshold of 33 cycles.
Clinical Significance:
a. Coronaviruses are a family of large RNA viruses with size ranging from 26 to 32 kb.
b. As the coronavirus is anRNA virus it has a relatively high mutation rate resulting in rapid evolution.
c. In December 2019,a new deadly coronavirus known as 2019-nCoV, which has a high sequence similarity to SARS-CoV, was
identified and has caused a pneumonia outbreak in Wuhan, China and spread globally.
Limitations:
a. The results of this test are highly dependent on the sampling technique employed, sample type, cold-chain maintenance
andclinical condition.  There is poor standardization between commercially available PCR tests, and results from different 
institutions should not be directly compared.  Results are best monitored using a single institution.
b. Presence of PCR inhibitors (cannot be traced by technologist),  specimen collected very early/late in infection or viral load lesser
than the assay lower limit of detection as wellas presence of rare genotypes or mutations may result in false-negative report.
c. False-positive report may be obtained in cases where there is possibility of background RNA contamination from pre
analyticalor in lab environment.
d. The assay performance characteristics for this test are determined by STMPL which is used for clinical  diagnosis. This test
isnot approved by FDA nor accredited by NABL or CAP.
e. RT-PCR kits used for this assay are approved by ICMR (Supratech Micropath Laboratory & Research Institute Pvt. Ltd. ICMR
No. SUPRA001f). Test performed on Quantstudio 5 Real-time PCR machine.

------------------ End Of Report ------------------

# For test performed on specimens received or collected from non-NSRL locations, it is presumed that the specimen belongs to the patient named
or identified as labeled on the container/test request and such verification has been carried out at the point generation of the said specimen by the
sender. NSRL will be responsible Only for the analytical part of test carried out. All other responsibility will be of referring Laboratory.

Note:(LL-VeryLow,L-Low,H-High,HH-VeryHigh ,A-Abnormal)

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Dr. Krutarth Shah Dr. Sandip Shah Printed On : 05-Jul-2022 17:49

M.D. Microbiologist M.D. (Path. & Bact.)

Consultant Pathologist