NOVEL CORONAVIRUS (COVID-19)

HPSL Employee / Contractor - Self Monitoring Form

Personal Information

Name: Ali Farooq Company: GNK

Designation: IT Officer Arrival Date at site: 5-11-20

Daily Employee Self-Monitoring

You have to check any of the following symptoms/conditions in 07 days prior to arrival at site. Please Tick YES or NO

Self-Monitoring Date: From __28-10.20____________ to __04-11-20__________

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

1) Flu ⬜ ⬜ ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
2) Fever (37.3°C or higher) ⬜ ⬜ ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
3) Cough ⬜ ⬜ ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
4) Breathlessness/Shortness ⬜ ⬜ ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
of Breathing Yes No Yes No Yes No Yes No Yes No Yes No Yes No
5) Sore throat ⬜ ⬜ ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
6) Is anyone in your family ⬜  ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
having above mentioned Yes No Yes No Yes No Yes No Yes No Yes No Yes No
symptoms?
7) Have you met or in close ⬜  ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
contact with any person with Yes No Yes Nov Yes No Yes No Yes No Yes No Yes No
above symptoms? 
8) Have you had close contact ⬜  ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
with or cared for someone Yes No Yes No Yes No Yes No Yes No Yes No Yes No
diagnosed with COVID-19?
9) Have you had close contact ⬜  ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
with big crowd? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
10) Have you traveled ⬜  ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
abroad/inland in past 14 days, Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If Yes please mention the
country name?
11) Have you had any other ⬜  ⬜  ⬜  ⬜  ⬜  ⬜  ⬜ 
symptoms? Yes No Yes Nov Yes No Yes No Yes No Yes No Yes No

Others: Please specify: ____________________________________________

Note: 1. If any of the above symptom/condition answered “Yes”, please seek advise from your Line Manager/Technical Officer.
2. Line Manager/Technical Officer shall consult Medical team for advise in case of symptom/condition reported ’Yes”.
3. Final completed form shall be submitted by employee to Medical team after signature prior to work commencement.
.

Declaration
I declare that all the information given in this form is true and correct

Signature: Ali Farooq Date: 04-11-20