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 Mahbub Alam
Employee ID 20100105
Designation Asst. General Manager
Department Passenger Car Division
Work station/Location Nitol – Niloy Center, 71 Mohakhali C/A, (5th Floor)
Age 40 Years
Supervisor Name & ID Mohammad Tanvir Shahid (117)

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: Bashundhara R/A, 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 Nothing serious to mention

N1/Supervisor’s Comments

CMO/DCMO Comments

……………………………. ………………………… …………………………….

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