Self-Disclosureby Contractor Employees [COVID-19]

Kindly answer the following questions, fill in the contact details and sign this disclosure form.

Question 1: Didyou or any of your first-degree relativesor domestic helperscome to Oman in the last 14 days?
[ ] Yes [ ] No
If answer to question is YES then mention the countries and dates of visit:
Countries visited or transited Date of Arrival in Oman Employee/Relationship

Question 2: Did you come in contact with any confirmed, suspected or quarantined person with new novel
coronavirus (COVID-19)?
[ ] Yes [ ] No
If answer to question is YES then: Date of contact ____/____/____ Where: __________________________________

Question 3: Are you presently suffering from any of the symptoms listed below?
Symptoms: fever with acute onset and/or cough with acute onset and/or shortness of breath, and/or diarrhea
and/or sore throat, and/or runny nose.
[ ] Yes [ ] No If answer to question is YES then:
Which symptom(s): ____________________________________ For how many days:
__________________________

Question 4: Are you staying in a lockdown area?

[ ] Yes [ ] No If answer to question is YES then: Location:
__________________________________
Question 5 - Are you presently suffering from any health condition that put you at higher risk of serious illness?
[ ] Yes [ ] No If answer to question is YES then:
Which health condition: [ ]Serious heart conditions / [ ] Asthma (moderate-to-severe)/ [ ] Chronic lung disease [
] Chronic kidney disease/ [ ] Chronic liver disease / [ ] Hemoglobin disorders / [ ] Cancer patient /
[ ] Immunosuppressive treatment / [ ]Uncontrolled Blood Pressure / [ ] Uncontrolled Diabetes / [ ] Pregnancy
[ ]Age more than (60) + chronic conditions / [ ] Severe obesity (BMI >= 40)

If you or first-degree relative family member or domestic helpers are currently in Oman, with past-recent history
of travel and have developed acute respiratory infection (sudden onset of at least one of the following: fever,
cough, shortness of breath), you shall cease coming to office/plantand immediately communicate with your line
manager and company focal point.
I, (My name mentioned below) acknowledge that the above information is correct, andI do accept the consequences on false
information.
Employee Name: Signature:
Employee ID #:
Location:
Manager: Employee Contact:
OQ Contract Holder Name: Date:

OQ – Occupational Health Department

COVID-19Self-Declaration Form by Contractor Employees - Form review: 06—02/06/2020