OP3030322GO0202

Application no:
30-05-2023 13:16:18 PM
Date and time:
Supraja Soundararajan
Customer name:
Suprajaac94@gmail.com
Email id:

Q1. In the last 3 months have you been tested positive for COVID-19* Yes ✔ No

Q2. In the last 3 months have you been self-isolated with symptoms on medical advice?* Yes ✔ No

Q3. In the last 1 month have you been advised to self-isolate due to COVID-19 (excluding mandatory government
Yes ✔ No
orders to remain at home)*

Q4. In the last 1 month did you have persistent cough, fever, raised temperature or been in contact with an
Yes ✔ No
individual suspected or confirmed to have COVID-19?*

Q5. Do you work in an occupation, where you have a higher risk to get in close contact with COVID-19 patients or
Yes ✔ No
with coronavirus contaminated material?*

Q6. Have you ever been tested positive for COVID 19 Yes ✔ No

6.1 Are you fully recovered? Yes No

6.1a Date of diagnosis

6.1b Date of recovery

6.1c Were you hospitalized for Covid19 treatment : Yes No

Q7. In the last 1 months have you or any of your family member been self-isolated with symptoms on
Yes ✔ No
medical advice?(excluding mandatory government orders to remain at home)

Q8. In the last 1 month did you have persistent cough, fever ,sore throat, nausea, vomiting ,diarrhea, difficulty in
breathing ,loss of smell and taste any other symptoms of coronavirus (COVID-19) and advised to do a
Yes ✔ No
Covid test or you/your family member have been in contact with an individual suspected or confirmed to
have COVID-19?

Q9. Do you work in an occupation like health care worker/Corona warrior Include (General Practitioners, Doctors,
Hospital Doctors, Surgeons, Therapists, Nurses, Pathologist, paramedics, Pharmacist, Ward helpers,
Individuals working in Hospitals/ Clinics having novel coronavirus (SARS-CoV-2/COVID-19) Ward ?) where Yes ✔ No
you have a higher risk to get in close contact with COVID-19 patients or with coronavirus contaminated
material ?

Q10. 10. Have you travelled abroad in last 15 days or intend to travel abroad in next 15 days Yes ✔ No

10.1 If yes :name of country

10.2 Expected date of arrival in India

10.3 Expected date of leaving India

Q11. Have you taken Covid 19 vaccine in last 7 days Yes ✔ No

Q12. Have you experienced any side effects post Covid vaccination Yes ✔ No

12.1 If yes, was hospitalization required to treat side effects Yes No

Electronically signed by Appili through One Time Password on 16/08/2021

12.2 Details of side effect experienced

Electronically signed by Appili through One Time Password on 16/08/2021