SELF DECLARATION FORM

Before the assessment starts, the assessor needs to provide certain information. Make sure that
the information assessor/technician will give is accurate and complete.

Name of the Assessor/Technician: _________________________________________________

Assessor ID: ___________________________________________________________________

AA name: _____________________________________________________________________

TP name: ______________________________________________________________________

TP SPOC name & contact no: ______________________________________________________

Location: ______________________________________________________________________

Assessment date: _______________________________________________________________

Scheme: _______________________________ Batch ID (if any): _________________________

 I have not travelled to any foreign location in the year 2020

 I am not being in contact with people being infected, suspected or diagnosed with
COVID-19

I declare that I am not experiencing any of the below issues:

 Fever
 Cough
 Shortness of breath
 Persistent pain in the chest

Has the Training partner prepared his center as per the guidelines provided by the
government? Yes No
Have the candidates worn masks & maintained social distance? : Yes No

I acknowledge that, the information I have given is accurate and complete.

Date:

Signature: