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COVID-19 Self Declaration Form

COVID-19 Self Declaration Form

    Personal Details

    Is your Residential Area under Seal Down?

    YesNoDon't Know

    Medical Details

    Have you experienced any of the following symptoms / suffering from any of the symptoms since the last 21 days?*
    FeverColdSore ThroatBody AcheDry CoughDiarrhoeaRunny NoseDifficulty BreathingNasal CongestionNon of Above
    Do you suffer from any other following pre-existing conditions?
    DiabetesHypertensionHeart DiseaseLung DiseaseNon of Above

    Interaction Details

    Have you had any contact with any person who has been diagnosed with COVID 19 in the last 21 days?*
    YesNoDon't Know
    Have you had any contact with any person who has been returned from abroad in the last 21 days?*YesNoDon't Know
    Has any of your family member / neighbour diagnosed with COVID 19 or kept under isolation in the last 21 days?*
    YesNoDon't Know

    Declaration

    I hereby declare that all the information furnished above is, to the best of my knowledge, true and correct and that no information has been omitted or withheld.
    I also further declare that I am fit to resume work at Miracle Electronic Devices Private Limited, and this declaration of readiness is not being made under any duress or stress.