SRM University – AP, Andhra Pradesh 522240

Pre-arrival self-declaration form

The Pre-Arrival Self-Declaration Form below should be filled-in and should be submitted to
the University no sooner than 72 hours and no later than 24 hours prior to reaching the
University. The PhD degree students should submit the electronic copy of the filled-in &
signed document to the respective research supervisor(s) (Guides) 72 hours before the
arrival at the campus. The research supervisor(s) (Guides) should forward their respective
PhD student’s Self-Declaration Form to the director, CLM 24 hours before their students’
arrival at the campus.
Part I: General Information and Travel History

Name: Yarramsetti saisrinu Register Number AP19235070005

Name of the Guide: Dr. M. Pardha saradhi Department. Chemistry

1. Emergency contact person name. Suryanarayana

2. Emergency contact person’s phone number. 7660901721

3. E-mail ID: Saisrinu978@gmial.com

4. Have you tested positive for COVID-19 and underwent treatment? No

5. Was any of your family members residing with you tested positive for COVID-19?

 Yes/ ☐ No.
If Yes, Date of testing positive 28/04/2021 (DD/MM/YY)
6. Have you tested yourself for COVID-19 in past 7 days? If yes, what is the result?

 Yes/ ☐ No.
If yes, please tick ☐ Positive /  Negative.

7. Have you experienced any cough/cold/fever during the last 14 days?

☐ Yes/  No.
If Yes, since when….
8. Please tick () if you are suffering from any of the health issues (e.g., allergy, asthma,
diabetes, hypertension, any heart diseases, immunocompromised individuals any other
major health condition etc) which are considered as high-risk group for COVID-19
infection (please tick):

☐ Yes /  No.
 SRM University – AP, Andhra Pradesh 522240
Pre-arrival self-declaration form

Arrival details:
9. Date and time of arrival: 18th July 2021
10. Mode of arrival [tick () on whichever is applicable]:
☐ Flight/ ☐ Train/  Bus/ ☐ Car -private/ ☐ Car-rented
11. Which place are you arriving to the University from/where are you arriving from?
Pendurru(village), Bantumilli(mandal), krishna(district), Andhra Pradesh.

Vaccination details: (Please tick)

12. Please tick whichever applicable

 ☐ Fully Vaccinated
 ☐ Partially Vaccinated
  Keen to get vaccinated
 ☐ Not Vaccinated for medical reasons
 ☐ Not willing to get vaccinated
Part II: Declaration

1) I shall strictly follow the University rules and regulations & the Standard Operating
Procedure (SOP) to combat and prevent COVID-19 at SRM University-AP campus. I
have read and familiarized myself with the SOP document.
2) I am returning to the University on my own willingness.

Signature

Date: 12-07-2021
Place: Pendurru

Supervisor’s Recommendation:
My PhD student Y. saisrinu Registered Number: AP1923507005 will reach the University
campus on 18-07-2021 (date) and 3PM time.
I assure you that my PhD degree student will abide by the rules and regulations of the
University and will strictly follow the recommended COVID-19 SOP procedures.

Signature
Name: Dr.M.Pardha Saradhi
Date: 12th July 2021
Place: Mangalagiri, Guntur, (district).