Self Declaration

The document is a Self-Declaration Form aimed at ensuring the health and wellbeing of employees and guests. It collects personal information, travel details, and health-related questions regarding symptoms and medical history. The form requires signatures for approval and is intended for use in a workplace setting.

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Self Declaration

Uploaded by

sagarbeleri708

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Available Formats

Download as PDF, TXT or read online on Scribd

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Doc no: VRPL-SHE-88

Self-Declaration Form
Rev no:00 dt 15.02.2024

SHE

Annexure 1: Self Declaration Form

You are requested to furnish the information to safeguard the health and wellbeing of yourself, Viviid
colleagues, families and communities.

Name of Employee/Guest as per Passport / Aadhar records: …………………………………………………..

Emp. No…………….. Mobile No. ………………..email ID …………………………………………………

In case arrived from outside the state / district, please share the start location…………………………..

Mode of travel (Air/ Train/ Road):…………………………………

Please mention Flight/ Train No / vehicle no. ………………………………………………

Arrival Date and Time………………………………..

Full Residential Address:

………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………….

Are you suffering from any of the following symptoms?

1. Fever Yes/No
2. Cough Yes/No
3. Respiratory distress Yes/No
Have you ever had any of the following?
 Diabetes, Yes/No
 Hypertension, Yes/No
 Lung disease, Yes/No
 Heart disease Yes/No
Have you interacted or lived with anyone tested positive with covid19 Yes/No
Have you completed covid19 quarantine Yes/No
Any other symptoms Yes/No

Signature: Date:

Approved by:
Signature: Date:

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Self Declaration

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Self Declaration

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Doc no: VRPL-SHE-88

Annexure 1: Self Declaration Form

Name of Employee/Guest as per Passport / Aadhar records: …………………………………………………..

Emp. No…………….. Mobile No. ………………..email ID …………………………………………………

Mode of travel (Air/ Train/ Road):…………………………………

Please mention Flight/ Train No / vehicle no. ………………………………………………

Arrival Date and Time………………………………..

Full Residential Address:

Are you suffering from any of the following symptoms?

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