COVID-19 Employee Consent

COVID-19 Employee Consent Form

Employee ID:
Employee Name:
Grade:
Location:
Department:

1. Are you showing any symptoms (fever / dry cough / sore throat / muscle pain / body ache)
related to COVID-19? YES / NO

2. Have you travelled from a different district/state in the last 14 days? YES / NO

3. If yes, name of the place you have travelled from _______________

4. Is anyone in your immediate family and staying with you (including room-mates) showing
any symptoms (fever / dry cough / sore throat / muscle pain / body YES / NO

5. Does your house fall in containment zone YES / NO

6. Have you downloaded Aarogya Setu application on your phone and taken a self-assessment
on the same? (please keep the location services ON for this app at all time for your own
safety and the safety of people in your contact at work or at home) YES / NO

7. Does your status on the Aarogya Setu application shows Green i.e. "you are safe / low risk of
infection"? YES / NO

8. You agree to wear a mask at all time during transit and in office YES / NO

9. You agree to carry and use personal sanitizer during transit (please note that the sanitizers
for use within office are available at the entrances and strategic locations YES / NO

10. You agree to adhere to all social distancing norms and arrangements during transit and in
office YES / NO

On Clicking Accept & Submit, I agree that I have gone through the above check items and
understand that these are for my own and my contacts' safety, both at work and at home. I
provide my consent to adhere to the above at all times.

Accept and Sign