CORONA PREVENTION FORM CORONA PREVENTION FORM

EMPLOYEE IDENTIFICATION EMPLOYEE IDENTIFICATION

Employee Code: Date: Employee Code: Date:

Employee Name: Employee Name:

Designation: Designation:

Time of Interview: Time of Interview:

Department: Department:

Loss of Loss of
* Fever * * Fever *
Smellof
Loss Smellof
Loss
* Cough/Flu/Allergy like * * Cough/Flu/Allergy like *
feeling taste feeling
Body Pain / taste
* Body Pain / Fatigue * Diaherea * * Diaherea
Fatigue
* Headache * Headache

OFFICIAL USE ONLY (Remarks if any) OFFICIAL USE ONLY (Remarks if any)

STATEMENT OF UNDERSTANDING: STATEMENT OF UNDERSTANDING:

I have been interviewed by concerned manager to assess my fitness to join work today.
I have understood and answered all questions on this form truthfully.
I have None/some of above mentioned symptoms
I fully understand and accept the precaution measures against Covid 19 (Corona Illness)
being implemented at my employer’s (MML) premises.
I have been interviewed by concerned manager to assess my fitness to join work today.
I have understood and answered all questions on this form truthfully.
I have None/some of above mentioned symptoms
I fully understand and accept the precaution measures against Covid 19 (Corona Illness)
being implemented at my employer’s (MML) premises.

Employee Signature and Date Manager HR Employee Signature and Date Manager HR