Health Department

COVID-19 self-declaration form

Please fill this form to declare your travel history, any existing illness or exposure to people suspected
or confirmed of having COVID-19 infection. This is to prevent an outbreak within the Atul community
and safeguard the health and safety of all employees and their family members.
Information collected will not be disclosed unless required by law.

Full name:
Employee number: Date of Joining:
Business: Department:
Location: Site:
Name of the contractor (applicable to contract employees only):

Declaration
Have you travelled outside India | Gujarat | Valsad district and returned
1 Yes No
on or after March 22, 2020?
If yes, please provide the following information:
Name of the area(s) visited (country | state | city):

Dates of travel (from | to):

Have you been in close contact with a person diagnosed with or

2 Yes No
suspected of being infected by COVID-19?
What is your relationship with the person?

Do you live in the same house?

What was the last date of contact?

3 Have you recently experienced any of the following symptoms?

Fever Yes No
Cough
Difficulty in breathing
Throat pain
Sneezing
Body pain | weakness
Date of initiation of symptoms:
 Health Department

Has the local health authority advised you, any of your family members or
4 Yes No
others with whom you share accommodation, to quarantine?
If yes, please share the following:
Date of being advised to quarantine:
Your relationship with the person who has been advised to quarantine:

Please confirm the following :

A I commute by my own vehicle and do not use public transport.
I have understood and shall abide by the following:
I. wash hands frequently with soap and water or clean using alcohol based
hand sanitiser
B
ii. maintain social distance of at least one metre at all times
iii. use personal protective equipment including face mask at all times
iv. dispose of used face mask in a yellow bag|dustbin used for bio-medical disposal

Current address of the employee: Mobile no:

Emergency contact no:
Employee signature:
Date:

For office use only

1. Body temperature:
If temperature is more than 100°F, do not permit the employee to enter the factory
premises for 14 days.
2. If the answer to any of the first four questions is “YES”, do not allow the employee
to enter the factory premises and he | she must be quarantined for 14 days.
3. The employee will be allowed to enter the factory premises only if a fitness
certificate is issued by the medical practitioners of the Company after the
completion of the said quarantine period.
4. The records of employees denied entry must be shared with the Health
Department on the same day.