Unilever India – Sites

Self-Declaration Form for Truck Driver/Cleaner

Name of Visitor : Date :

To prevent the spread of COVID-19 in our community and to ensure we are protecting you and we are
protecting each other we need to ensure that anyone attending a Unilever site completes a simple
confirmation below. This helps us to maintain a safe and healthy workplace.

If you answer YES to any of the questions below, you will not be able to enter a Unilever site
without further consultation with your local Unilever Medical & Occupational Health Team. Please
ensure you download and save your declaration and discuss your specific details with your Unilever Medical
& Occupational Health Team. This is for the protection of your health and that of others.

If you start to develop symptoms on the morning that you are due to arrive at Unilever site, please stay at
home and inform your HUL contact or transporter contact.

Please note that it is a breach of our Code of Business Principles if you provide information in this form that
you know is false or misleading. Please answer this form truthfully. If you have any questions regarding any
part of this form, please contact Line Manager or HUL Contact.

Thank you for your time and support.

Sl. Check points (√) Correct one

1 Personal Details
1.1 In the last 14 days, have you or family member had any of the following YES NO
COVID-19 symptoms?

• Fever (37.5 C / 99.5 F or above)

• A new cough, if you usually have a cough, a worse than usual cough

• Breathlessness

• Sore throat

• Generalised body muscle ache (not localised from recent

exercise/physical activity)

• Headache (only in combination with any of the other symptoms)

• Loss of taste or smell

1.2 In the last 14 days, have you or family member tested positive for COVID-19? YES NO
 1.3 Have you or family member attended Public gathering e.g marriage YES NO
ceremony, political rallies or any crowded places
1.4 In the last 14 days, have you or family member been in close contact with a YES NO
person who has any of the above COVID-19 symptoms, or who has been
diagnosed with COVID-19? (“Close contact” means having face to face contact
at a distance of less than 2 metres/6 feet for more than 15 minutes.)

1.5 In the last 14 days, have you or family member returned from international YES NO
travel or Other state or Containment zone?

1.6 Are you or having : YES NO

Aged 65 or over
A chronic lung condition (such as asthma, cystic fibrosis or COPD)
Heart disease and/or high blood pressure
Diabetes
Cancer
Chronic kidney disease
Liver disease (such as hepatitis)
A condition that means you have a high risk of getting infections (such as
sickle cell, lupus, HIV, scleroderma, asplenia, blood or bone marrow cancer)
Taking medicine or treatments that make you more likely to catch infections
(such as steroids or immunosuppressants, chemotherapy or cancer
treatments, or a bone marrow transplant within the last 6 months)
A BMI (Body Mass Index) of 40 or over
Any other diseases according local law/practice/situation, which are seen
as increased risk and not listed above
Note : "If your answer to any one of the above questions is/are YES please report to security and wait for the
guidance"

1. I confirm that my answer to all the questions above is “NO” [tick box].

OR

2. I confirm that, if any of the answers to the questions above are YES, I will not attend a Unilever Site without prior
discussion with Unilever Medical & Occupational Health Team. [tick box].

In the event of a YES declaration above, your entry to site will need to approved by Unilever Medical & Occupational Health
Team and you confirm that you will follow the conditions and advice they have given you.
I acknowledge that the information I have provided above is accurate and complete.

Signed:

Date:

Entry to Unilever Site Approved by:

Name:______________________________

Signed:

_____________________________

Date:

Unilever Medical & Occupational health