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01
Date:13-05-2020
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Safety Declaration form for Visitors

We have taken every precaution at our premises for the safety of our employees and our surrounding communities
and we have implemented every safety practice to keep you safe during your visit to our premises. We ask all
visitors to our premises to fill this declaration form so that we can stop the spread of COVID-19, together.

Part I – To be completed by visitors to CBL premises

1. Name: M. R. Yattigala……………………………………………………………………………………..

2. N.I.C No: ………l……………………………………………………………………………………………………………….

3. Permanent residential address: ……Sri Gunarathana Mw, Mount Lavinia...........................

4. Current residential address: …………Same……………………………………………….

5. Grama Niladhari Division of current address: …………Wathumulla, Mount Lavinia…………...

6. Phone No (Home & Mobile): ………………0719109595……………………………………………………….

7. Company Name and Address: ………408A, Nungamugoda, Kelaniya, Sri Lanka.……………………….

8. Reason for visiting CBL: ……Meeting with Mr. Roshan Serasinghe……………………………….

9. Name of employee you will be meeting at CBL: ........... Mr. Roshan Serasinghe...........................….

10. Department of the employee you will meet: ................Logistics............................................…….

11. Date and time you plan to visit CBL:……04 th June 2020 9 am……………………………………….

12. Have there been any positive Covid - 19 cases reported in the area of your residence (1 km
radius of residence) within the last 30 days? …………………No………………………………

13. Are there any houses/buildings quarantined in the area surrounding your residence? If yes,
please specify reason for quarantine? …………………No…………………………………………………………
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….………………………………………………………………………………………………………………………………………………………………

14. Are you travelling from a high risk area or an area which has been placed in isolation? If yes,
reason? …………………………No……………………………………………………………………………….….………………………………...
………………………………………………………………………………………………………………………………………………………………….
.

15. Have you travelled abroad recently? If yes, please specify Country and Duration of travel
……………
No……………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

16. Have you had close contact with any person who travelled to Sri Lanka from any other country
recently? If yes, please specify who (relationship), Country of travel and duration of travel?
……………………
No……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………….

17. Have your family members had close contact with any person who travelled to Sri Lanka from
any other country recently? If yes, please specify Country and duration of travel?
………………No…………………………………………………………………………………………………………………………….
….………………………………………………………………………………………………………………………………………………………………
18. If you have the following symptoms please mark the box (✔), if you do not have these
symptoms please mark the box (X)

I. Fever X
V. Shortness of Breath X
II. Dry Cough X
III. Cold X VI. Diarrhea X
IV. Difficulty in Breathing X
VII. Headache X
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Guidelines to be followed by visitors at the premises:

● If you have any of above symptoms, we ask that you do not visit our premises. In such case, please
inform your CBL contact and follow the government mandated instructions for your safety.
● Please bring with you only the minimum essential belongings you need for your purpose.
● We have provided hand washing, sanitizing and foot sanitizing facilities. Please sanitize your feet
and wash and sanitize your hands before entering the reception area (Our security officers will
guide you to our waiting area)
● Please note that your temperature will be monitored at the entrance.
● Face masks must be worn at all times within the premises
● Should you feel the need to sneeze or cough when you are at our premises, please cover your face
with a disposable tissue or your elbow
● Please dispose of your used tissues immediately into bins assigned for this purpose
● Please ensure that there is always a minimum of 1m distance with any personnel you come into
contact with at our premises
● We will provide you with a guide who will escort you to your destination within our premises,
please remain with your escort
● We ask that you follow all safety protocols and procedures communicated to you during your visit
to our premises.

I certify that the information declared by me is true & accurate and agree to fully cooperate with the
guidelines for visitors and all safety measure required by CBL during my visit to the CBL premises.
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Name of the Visitor: ……M. R. Yattigala………… Signature of Visitor: ……………………………………………..

Date: ……………………………..

Reviewed on behalf of SHEQ team by ;

….…………………………………………………. …………………………………………………
SQAM (Shyama Rajapaksha) SHEM (Dileep Sameera)

Part II- To be completed and certified by the relevant CBL Head of Department following the visit

Department of EPF number of Time spent with Location of contact with visitor
Employee visitor
Employee
From: To:

I certify that the meeting took place within the regulations for social distancing and all required
sanitization activities were successfully carried out upon completion of the visit.

Name & signature of the HOD : …………………………………………………………………..

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Date : ………………………………………………………………...