Coronavirus Self Declaration Form
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Employee Name/ Customer Name / Vendor or Supplier Name
First Name
Vehicle Number
Vehicle
Two Wheeler
Four Wheeler
Emp ID & Department
Emergency Contact Person & Number
I am healthy & in perfect condition to work in the office?
Yes
No
Your residential Address with Ward No. & Zone Status
Country, State, City
Any Travel History (Out of Bengaluru)
Arrival and return dates for each area
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
Yes
No
If yes, please specify name of person, relationship & Address, Contact Number
Please state whether you've experienced/are experiencing the following
Rows
Yes
No
Fever
1
2
Cough
3
4
Shortness of Breath
5
6
Persistent Pain in the Chest
7
8
Is your family members having above mentioned symptoms of COVID-19?
Yes
No
I acknowledge that the information I've given is accurate and complete.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: