Undertakin on self - isolation

Aged resident or _

----------------------- Bein& dlaanosed as a

confirmed / suspect case of of COVID- 19 on

---------------, do hereby voluntarily undertake to maintain

strict self-lsolutlon at all times for the presc.ribed period.Dur ng th s period I shall monitor my

health and those around me and Interact with the assigned survelllnace team I with the call

center (107S),In case Isuffer from any deteriorating symptoms or any of my close family

contact develops any symptoms consistent with COVID 19.

Ihave been eMplalned In detailabout the precautions that Ineed to follow while Iam under self

-iso ation.

Iam llable to be acted on under the prescribed law for any non- adherence to self-

Isolation protocol.

Signatur

e Date

Contact Number

(NOT TOBE SWITCHEDOFF AT All)

1)2BHK/1BHK/ RK :

2) NO.OF TOILETS :

3) NO.OF FAMILY MEMBERS :

4) SYMPTOMS IF ANY (Y/N) :

S) COMORBIOITYIF ANY :
(COMPUSORY)
6) DOWNLOADED AAROGYA SETUAPP (Y/N) :

7) DETAILS OF DOCTOR FROM WHOM GOING TO TAKE TREATMENT: (COMPUSORY)