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
Employee ID
Designation
Department
Work station/Location
Age
Supervisor Name & ID

2. Information during Covid 19 Lockdown

a. Where is your work location/station:………………………………………………..
b. During last seven days, where did you stay: ………………………………………
c. Do you had fever, cough, cold, body pains etc. in last seven days: ……………..
d. Do any of your family members have any of the above symptoms or travelled abroad/
anywhere during last two weeks & location :………………………….....
e. Were you in-person contact with any suspected case of Covid-19/ fever, cough, cold,
body pains etc in last two weeks :……………………………………………..
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

N1/Supervisor’s Comments

CMO/DCMO Comments

……………………………. ………………………… …………………………….

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