SELF DECLARATION AND ASSESSMENT FORM COVID-19

VISITORS

NAME R.A SASINDU NIRMAN

N.I.C. NO 961623502V
ADDRESS 371/5,Parangoda,Dekatana
CONTACT NO. 0771719545
DATE & TIME
OF VISIT
NO YES If YES, please provide details

ARE YOU NAME OF VACCINE SYNOPHARM
VACCINATED
FOR COVID-19? 01ST DOSE - DATE 07/17/2021 02ND DOSE - DATE 08/17/2021
NO YES
PFIZER BOOSTER BOOSTER DATE

SYMPTOMS - Please Tick  YES NO

1 Do you have a runny nose? 
2 Do you have a cough? 
3 Do you have a sore throat? 
4 Do you have fever? 
5 D you have difficulty in breathing? 
HISTORY OF EXPOSURE - Please Tick  YES NO
Have you associated with any person(s) who travelled out of Sri Lanka and back
6 
during the past 14 days?
7 Have you had any contact with those being isolated or diagnosed with COVID-19? 
Are you residing next to a house that is being isolated or had a patient diagnosed
8 
with COVID-19?
Have you participated in any form of mass gathering (Party, Funeral, Meeting)
9 
during the past 14 days?
10 Have you had any contact with a typical pneumonia / cold or cough? 
If you have answered YES to any one of questions above, kindly refrain from entering our office premises.
I Hereby certify that above details are true and correct.
Sasindu 10/21/2022
…………………………………………… ……………………………………………
Signature of Visitor Date

D. Samson & Sons (Pvt) Ltd – Human Resources