AgniVeer 01/2022 (21st – 31st July, 2021)

Self-Declaration – COVID-19
Name: __________________________________________________Id Proof: _________________

Centre Code: _______ Centre Name: __________________________________________________

City: _______________ ATC’s / C-DAC Centre’s Name: _____________________________________

1. Do you have any of the following flu-like symptoms:

a. Fever (38 degree or higher)  Yes  No

b. Cough  Yes  No
c. Breathlessness  Yes  No
d. Sore throat  Yes  No
e. Others: Please specify  Yes  No

2. Have you or an immediate family member come in close contact with a confirmed case of the
coronavirus in the last 14 days? ("Close contact" means being at a distance of less than one metre
for more than 15 minutes.)  Yes  No

I hereby declare that all the information mentioned above is true to the best of my knowledge and
will immediately inform to Covid -19 Central/State Govt. authority, if any symptoms arise during or
after examination.

Signature: Date: Place:

AgniVeer 01/2022 (21st – 31st July, 2021)

Self-Declaration – COVID-19
Name: __________________________________________________Id Proof: _________________

Centre Code: _______ Centre Name: __________________________________________________

City: _______________ ATC’s / C-DAC Centre’s Name: _____________________________________

1. Do you have any of the following flu-like symptoms:

a. Fever (38 degree or higher)  Yes  No

b. Cough  Yes  No
c. Breathlessness  Yes  No
d. Sore throat  Yes  No
e. Others: Please specify  Yes  No

2. Have you or an immediate family member come in close contact with a confirmed case of the
coronavirus in the last 14 days? ("Close contact" means being at a distance of less than one metre
for more than 15 minutes.)  Yes  No

I hereby declare that all the information mentioned above is true to the best of my knowledge and
will immediately inform to Covid -19 Central/State Govt. authority, if any symptoms arise during or
after examination.

Signature: Date: Place: