SELF DECLARATION - COVID 19 PRE SCREENING

Date: Contact No:

Name : Designation :
Company Name: Age:
Sl no Check points Answer

1 Are you suffering from any of the following health issues

•Runny nose
•Sore throat
•Headache
•Fever
•Cough
•Feeling of being unwell
•Difficulty in breathing
2 Where are you staying during this Lock down?
District:
Locality /Village name: City /Taluk:

3 Are you from COVID containment zone?

4 Are there any COVID infected person neighbouring to you?

5 Have you visited any COVID Contonment zone area?

6 Did you have any interaction with any body staying in COVID containment zone?

7 Is any of your family member suffering from above health symptoms?

Have you undergone quarantine during Lockdown? If yes When did your quarantine
8 period end?

9 is your area declared as RED ZONE?

10 Any of your relatives suffering from CORONA?

11 If yes---name & relation

12 Any of your friends suffering from corona?

if yes--Name & location

13 What personal care you followed during the lock down period?

14 Other than CORONA---- Do you have any other health issues in last 30 days?
If yes---Name the illness & current status.

Have you Downloaded & installed Arogya setu App & Apthamitra App? If not please download
15 & keep the Blue tooth ON.

16. Do you feel attending the work may be harmful to you & others, If yes, please mention the reason:

17. Name the places you have visited since 15.03.2020:

I Declare that all the information mentioned above is true

Signature Date: