APPENDIX D

SCREENING FOR COVID-19

SELF ASSESSMENT & DECLARATION FORM

Watch for symptoms

People with COVID-19 have had a wide range of symptoms reported – ranging from mild
symptoms to severe illness.

Symptoms may appear 2-14 days after exposure to the virus. People with these symptoms or
combinations of symptoms may have COVID-19:
 Cough
 Shortness of breath or difficulty breathing
Or at least two of these symptoms:
 Fever
 Chills
 Repeated shaking with chills
 Muscle pain
 Headache
 Sore throat
 New loss of taste or smell
This list is not all inclusive. Please consult your medical provider for any other symptoms that are
severe or concerning to you.

Self Assessment & Declaration Form

Student No.
Name
Designation/ Course
Department/ Semester
Area spent last 14 days
Zone as declared by Govt Containment/ Non Containment
Do you have

1. Fever - Yes/ No/ Do not Know

2. Cough - Yes/ No/ Do not Know
3. Sore throat - Yes/ No/ Do not Know
4. Difficulty in breathing - Yes/ No/ Do not Know
5. New loss of taste or smell - Yes/ No/ Do not Know
6. Any other ailment-
7. Any body in your close circle and family found to be Covid – 19 Positive in last two
weeks-Yes/No

Date Signature of Student

 APPENDIX E

UNDERTAKING BY STUDENT & PARENT

I,Name_____________ University Roll No.__________________ Department_______________

Course__________________Sem__________

Have read the Guidelines to restart the University Post Covid-19 and undertake to follow them in

letter and spirit. If I am found not following them then I am liable for strict disciplinary action by

the University.

I shall be joining the campus at my own risk, liability and consequences.

Signature of the Student Signature of the Parent

Date Date
 APPENDIX F

CONSENT OF THE PARENT

1. I/ We am/ are parent of Name_________________________________University Roll

No_______________________Department_______________________Course___________
_______Semester__________________
2. We are in receipt of mail/letter from Chitkara University about reopening of the University
based on Govt Guidelines.
3. We consent to send our ward to the University to attend the classes as day scholar/
hosteller.
4. Our ward will take all necessary precautions issued by the Govt of India and Chitkara
University against Covid 19.
5. In case our ward contacts Covid 19 during his/her study at Chitkara University Punjab, the
University will not be held responsible for the same.

Name of Parent:

Signature of Parent
Date:-