AARTI INDUSTRIES LIMITED   
SOP FOR WORK RESUMPTION AFTER SHUTDOWN DUE TO COVID-19  
DOCUMENT NUMBER:: AIL/SFT/SOP/00 
WEF 09/April 2020 

10.4  Annexure  :  4  -  ​Medical  Questionnaire  for  Employees/Contract 

Worker 
Medical Questionnaire for Employees/Contract Worker 
(​Only those persons shall be considered whose all responses are 'NO'  Response 
Sr No. except point 8e & 8f is for information; 
DH or FH shall decide for resumption of employees duty in case of any 
(Y/N)
deviations​)
1 Have you been advised home quarantine by Govt. officials ?
Have you come in contact with any person who has been Home 
2
Quarantined by Govt. Officials ?
3 Are you above 50 years of age ?
Do you suffer from any of these conditions (If yes, then cross check 
4
with FMO)
a Diabetes
b Blood Pressure
c Post Heart Attack
d Asthma or Breathing Difficulty
e Kidney related ailment
f Cancer
Have you travelled outside of the specified areas in the below 
5
respective sites in the last 14 days ?
VAPI SITE -​ VAPI/VALSAD/NAVSARI/DAMAN
TARAPUR SITE - T
​ ARAPUR
MAHAPE SITE -​ NIL DUE TO HOT SPOT
JHAGADIA SITE -​ BHARUCH DIST EXCEPT AMOD TALUKA
DAHEJ SITE -​ BHARUCH DIST EXCEPT AMOD TALUKA
KUTCH SITE -​ KUTCH DIST EXCEPT MADHAPUR & LAKHPAT
Note : Update on 11.04.2020, 13:30 hrs. The list of areas will be 
updated as per latest findings, if any by respective FMO's
Are you suffering from Fever/Cough/Sore throat/Runny 
6
Nose/Difficulty breathing ?
7 Do you commute to work in shared/public transport ?
8 Do you have any family member at home : -

The  copyright of this document is vested with Aarti Industries Ltd. Neither the whole nor the part of this document may be reproduced, stored in any 
retrieval  system  or  transmitted  in  any  form  or  by  any  means  (electronic,  mechanical,  reprographic,  recording  or  otherwise  without  prior  written 
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AARTI INDUSTRIES LIMITED   
SOP FOR WORK RESUMPTION AFTER SHUTDOWN DUE TO COVID-19  
DOCUMENT NUMBER:: AIL/SFT/SOP/00 
WEF 09/April 2020 

a Who has returned from a foreign country ?

b Who has been advised home quarantine by Govt. officials ?
Who has travelled outside of the specified areas in the below 
c
respective sites in last 14 days ?
VAPI SITE -​ VAPI/VALSAD/NAVSARI/DAMAN
TARAPUR SITE - T
​ ARAPUR
MAHAPE SITE -​ NIL DUE TO HOT SPOT
JHAGADIA SITE -​ BHARUCH DIST EXCEPT AMOD TALUKA
DAHEJ SITE -​ BHARUCH DIST EXCEPT AMOD TALUKA
KUTCH SITE -​ KUTCH DIST EXCEPT MADHAPUR & LAKHPAT
Note : Update on 11.04.2020, 13:30 hrs. The list of areas will be 
updated as per latest findings, if any by respective FMO's
d Who has Fever/Cough/Sore throat/Runny Nose/Difficulty breathing ?
e Who is above 60 years of age ?
f Who is above 40 years and having any chronic conditions like : -
i Diabetes
ii Blood Pressure > 160/100 mmHg
iii Post Heart Attack
iv Asthma or Breathing Difficulty
v Kidney related ailment
vi Cancer (irrespective of age)

I hereby declare that, to the best of my knowledge and belief, the particulars given above and the 
declaration made therein are true and I will abide by the precautionary measures advised by the AIL 
Management.

Name of Employee / Contract Worker :

Function / Contract Name :
Employee Code :
Date :
Sign :
 
 

The  copyright of this document is vested with Aarti Industries Ltd. Neither the whole nor the part of this document may be reproduced, stored in any 
retrieval  system  or  transmitted  in  any  form  or  by  any  means  (electronic,  mechanical,  reprographic,  recording  or  otherwise  without  prior  written 
consent of the copyright owner)