Annex- A

Nitol Niloy Group

Nitol Center
71, Mohakhali C/A, Dhaka-1212.
Post Lockdown (Covid-19) Clearance Form

This form must be submitted two days earlier on the day of Office Re-opening
1. Employee Information

Employee Name MD. JUBAIR NEWAZ

Employee ID 20140811
Designation EXECUTIVE
Department PASSANGER CAR DIVISION
Work station/Location Nitol – Niloy Center, 71 Mohakhali C/A, (5th Floor)
Age 31
Supervisor Name & ID Mahbub Alam (20100105)

2. Information during Covid 19 Lockdown

a. Where is your work location/station: 71, Mohakhali C/A, Dhaka

b. During last seven days, where did you stay: MIRPUR-1, DHAKA
c. Do you had fever, cough, cold, body pains etc. in last seven days: NO
d. Do any of your family members have any of the above symptoms or travelled abroad/ anywhere during
last two weeks & location : NO
e. Were you in-person contact with any suspected case of Covid-19/ fever, cough, cold, body pains etc
in last two weeks : NO
3. Short health history
Do you have underlying medical complications:

Yes No Comments
Diabetes √
Cancer √
Heart/Cardiac disease √
Liver disease √
Kidney disease √
Neurological disease √
Respiratory disease √
Any other please mention Not any serious Issue

N1/Supervisor’s Comments

CMO/DCMO Comments

……………………………. ………………………… …………………………….

Employee’s Signature N1/Supervisor Signature CMO/DCMO Signature
with ID & Date with ID & Date Date