Self Declaration and Health Screening Form
Uploaded by
Kumar PranaySelf Declaration and Health Screening Form
Uploaded by
Kumar Pranay12/5/2020 Self Declaration and Health Screening Form
Self Declaration and Health Screening
Form
* Required
Email address *
Your email
Name *
Your answer
Roll Number *
Your answer
Programme *
PGP
IPM
PGP HRM
EPGP
Other
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12/5/2020 Self Declaration and Health Screening Form
Contact Number *
Your answer
Present Residential Address *
Your answer
Please state the reason(s) for seeking permission to come to campus. *
Your answer
Are you presently staying at a location which is the containment zone of COVID-
19? *
YES
NO
Did you test positive for COVID-19 infection? *
YES
NO
Is yes, please specify when
Date
dd-mm-yyyy
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12/5/2020 Self Declaration and Health Screening Form
Were you isolated or quarantined by COVID-19 team? *
YES
NO
Did any of the individuals you are currently living with test positive for COVID-19
infection? *
YES
NO
History of contact with COVID-19 case *
Lab confirmed case of COVID-19
Suspected case under investigation
No contact
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12/5/2020 Self Declaration and Health Screening Form
Are you suffering from any of the following symptoms? *
YES NO
Fever
Cough
Difficulty in Breathing
Sore throat /Running nose
Headache and Malaise
Is any individual you are currently living with suffering from: *
YES NO
Fever
Cough
Difficulty in Breathing
Sore throat /Running nose
Headache and Malaise
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12/5/2020 Self Declaration and Health Screening Form
Are you suffering from any chronic illness like Diabetes Mellitus, Hypertension,
Heart disease, COPD, Asthma, Chronic Renal Disease etc or are on
immunosuppressant drugs? *
YES
NO
If Yes, please provide details
Your answer
Any other illness (please provide details)
Your answer
History of any Psychological/Psychiatric illness (to be specified)
Your answer
Did you have a history of travel within India in the last 4 weeks? *
YES
NO
If Yes, please specify the following: (a) Place & Duration of stay
Your answer
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12/5/2020 Self Declaration and Health Screening Form
(b) Date of Arrival
Date
dd-mm-yyyy
(c) Date of Departure
Date
dd-mm-yyyy
(d) Mode of travel
By air
By train
By bus
Taxi
Personal vehicle
Other:
Remarks, if any
Your answer
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12/5/2020 Self Declaration and Health Screening Form
Declarations *
I hereby declare that the information given in this form is true and correct to the best
of my knowledge and belief.
I am coming to the campus voluntarily. The Institute, faculty, or staff are not liable in
any form for my actions or consequences thereof.
My parents/guardians have been informed that coming to campus is voluntary. I and
my parents/guardians are also aware that all responsibilities related to my stay on
campus are mine.
I acknowledge that if any information provided by me is found false, disciplinary
action will be initiated against me.
A copy of your responses will be emailed to the address you provided.
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