MOL Pakistan Oil and Gas Co. B. V.

SD&HSE |COVID 19-00Y20 |REV03|02nd May 2020

Health Declaration Form

&
Questionnaire
MOL Pakistan Premises

1. Have you or one of your family member travelled internationally or within the country in the
last 14 days or less?
o YES
o NO
State Country / City you travelled --------------------

2. Are you suffering or have been suffering from any of the following during last 14 days?
o Fever / Flu YES/ NO
o Cough YES/ NO
o Shortness of breath YES/ NO

3. Have you, or anyone whom you share a residence with, been in contact with any person
suffering or suspected to be suffering from Covid-19 in the last 14 days?"

o YES
o NO

4. Have anyone of your immediate family, friend or relative been diagnosed / or symptoms of
CORVID19 in the last 14 days?
o YES
o NO

5. Have you remained in home isolation for 07 days without any external contacts / exposure
before starting the journey for MOL field
o YES
o NO
Please specify the number of days if answer is NO -------------------------

I hereby declare that the above answers and statements are true and complete. I am otherwise in
good health, I confirm that I have checked and found correct all answers and statements in this form.

MUHAMMAD SHABBIR
NAME: ___________________________

SAF ENGINEERING
COMPANY: ________________________

03008523548
CELL NUMBER: ______________________

Temperature noted at the field gate: __________________