DICHIARAZIONE RESA AI SENSI DEGLI ARTICOLI 46 E 47 DPR N.

445/2000

TO BE SIGNED BEFORE ENTERING CLASSROOM

(to be consigned to the person responsible - in capital letters)

THE UNDERSIGNED (SURNAME FIRST NAME)

________________________________________________________________________

NATIONALITY _____________________, BORN IN ________________________ ON

______________________________________ NATIONALITY_______________________________

PASSPORT/Document No ______________________ ISSUED ON ____________________________

BY_______________________________________________________,

UNDER MY OWN RESPONSIBILITY AND IN ACCORDANCE WITH THE REGULATIONS IN FORCE, DECLARE AS
FOLLOWS:

1) that I am not subjected to a period of compulsory or voluntary quarantine for the least 14 days;

2) that I am not currently suffering from a feverish illness with a temperature above 37.5° C;

3) that I am not currently suffering from a persistent cough or diarrhoea, have no difficulty in breathing, or
have a cold, sore throat, headache, severe asthenia (fatigue), or a decrease or loss of smell/taste;

4) that I have had no close contact with a person suffering from COVID-19 in the last 14 days;

CITY__________________________________________, PROVINCE__________________

ADDRESS_____________________________________ NO. ________ POSTAL CODE__________

TELEPHONE NUMBER______________________ e-mail_____________________________

The present declaration is issued as prevention measure related to the COVID-2 pandemic.

Place and date: ___________________, ____________________.

Yours faithfully

Legible signature of the Declarant