Health Declaration Form cee Clad) CA gai Due to the ongoing and rapidly changing situation with the novel-coronavirus (COVID-19) we are requiring all ‘employees prior to get back to office to fill-out the self- declaration form below. ITC will make a decision on access to the premises based on the answers provided below. Please resend this form back to HR before 24 hours prior to your report to work Pees (Click oF tap here to ener text asell geld Guill go Tepe tally Spe ell Gh Sal CH 5p 8 celal ayes Ga ILS ld « (COVID-19) BS yD BG yeas iy oll) Gacall platy 23 ad al 5 78 phan Ss sal ly U pall Gls 41a | 28 AB Hp 2 hyall GM Zell vey gyal A Doo! Ble] gas AS ie eg gal Baa Ge del [CS Va palette: BETIS NTE TER ick or tap hereto enter tex ZLFOF — Click orton hore ta ontor text 4.Do you have any uf te following fu-ike symptoms? | Yes | No SIMA Hasna ANG GL FT Ge gl eal Dh = Fever (38° or higher). Oe GSI 338) = = Cough, o|e - = Breathlessness, ole - = Sore throat. fol es aaa = Others. please specity if Yes: | ee] SS Go eR OS eal Click or tap here to enter text. i ick or tap here to enter text 72.Have you or an immediate family member come in is EE Onl ied A asl J close contact with a confirmed case of the coronavirus DANN") Mags 14 AF BUS egy Oe bhp Ley in the last 14 days? (“Close contact” means being at a SY sal sa Sa Hl Mile le et ol ote Mtl distance of less than one mater for more than 25] - | rp (aks 15 ow james.) Us a38 casa On Sale Ue ee ay ua igh cals it U have been in close contact with a confirmed case of Aytl 440 ipl gh Coronavirus in the last 14 days. | ° 3.Please Select the status According to TAWAKLNA App ks ee oe ORI GIS Immune &|oO — ‘No record of infection folo aid Infected olo hee Home Quarantine ojo Ala sas Institutional Quarantine olo eau a ‘This document wil be retained confidentially by ITC for after submission, ‘The health and wellbeing of aur community iz our frst prorty therefore WC reserves the right to deny entry to the office in any prove of sickness I hereby declare that the details furnished above are true and carrect to the best of my knowledge and belief, and informed about the policy of it. undertake the responsiiity to inform you of any changes therein, J immediate. signature: cick or tap here to enter tet Date: spd Gh A Ah gg ay a Ay iy 1) Be Led clad ol KBs ly 1h Ug ya Abd aan AY ttl de Be At fe Uh a gh a a es sn ol ef vas Hl sll a kt gh Jak DM sl aU ly ==> asa Click or tap nee to enter text. sgh (5/11 2222 a]