COVID-19 Coronavirus Exposure Questionnaire for worker/staff of Contractor

Employee Name:

Age:

Gender: (Male / Female)

Native (State, District/City, Village):

Please answer the following questions with as much details as possible
1. Location / Travel Declaration
a. Please provide your location / travel patterns over the past 14 days
STATE CITY VILLAGE DATE ARRIVED / SINCE DATE DEPARTED
WHEN YOU HAVE BEEN AT THE
LOCATION

2. Any cases of COVID-19 in your location where you have been for last 14 days?
YES NO

3. Are you, or have you been in close contact with anyone who has been quarantined or who has been
diagnosed with Novel Corona virus (COVID-19)? If yes, please provide details.
YES NO

4. Have you ever been quarantined due to a possible exposure to Novel Corona virus (COVED-19)? If yes,
please provide dates and locations.
YES NO

5. Have you experienced any of the following symptoms within the last 14 days?
a. Any fever YES / NO
b. Cough YES / NO
c. Shortness of breath YES / NO
d. Tiredness YES / NO
e. Mucus discharge from the nose YES / NO
f. Sore throat YES / NO
g. Vomiting and/or diarrhoea (loose motion) YES / NO
If answer for any of above is yes, then please provide full information.

6. Are you currently in good health?

YES NO
DECLARATION:
I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any
material information that may influence the assessment or acceptance of this application.
I agree that this form will constitute part of my application for insurance(s) and that failure to disclose any
material fact known to me may invalidate my insurance(s).

Signed at on this day of-

Worker's/Staff Name & Signature/Thumb impression