Appendix 'A'

(Refer to Para 1(d))

Place for photo

SELF DECLARATION FORM (Do not paste

before reporting to
centre)
1. Name:
Signature
2. Registration No:

3. Do you currently have or had any of the following symptoms in past 07 days?

(a) Fever Yes No

(b) Sore Throat Yes No
(c) Cough Yes No
(d) Running Nose Yes No
(e) Breathing difficulty Yes No

4. Did you meet/ have close contact with any confirmed COVID-19 person in the past 14
days?

Yes No

5. Did you have any history of domestic or international travel in the past 14 days?
(Other than travel from home station to PFT center)

Yes No

6. I declare that I am under no medication.

7. I declare that the statements made by me are true to the best of my knowledge.

(Signature of Individual)

Place:

Date:

Page 3 of 3