NAWCOD & NAPED

HEALTH DECLARATION FORM (Coronavirus - COVID19)

Name Badge/ID Company Date

Read carefully the below questions and answer them with transparency:

Do you have any of the following symptoms? Yes No If any of the above questions’
answer is YES, obtain medical
Cough clearance from your in-
kingdom medical provider prior
Shortness of Breath, Breathing Difficulties to reporting to Saudi Aramco
work locations.
Fever (High Temperature)

Digestive Symptoms

Runny nose

Headache

Sore Throat

Feeling of being unwell

Were you in direct contact with a person who has

been diagnosed with the novel coronavirus COVID-
19?

Have you or your in-kingdom dependents visited any

of the below countries in the past 14 days?
(Including transit flights).

(China, Italy, Iraq, Malaysia, Iran, Japan, Afghanistan, Lebanon, South

Korea, Singapore, India, Pakistan, Bahrain, Kuwait, Egypt) If other
(please mention it):

I recognize that failure to do the above actions, or providing false information, may
result in severe disciplinary actions.

Date: _____________ Signature: ____________________

HAND THIS APPLICATION TO THE RESPONSIBLE EMPLOYEE

Saudi Aramco: Company General Use