A)I/my family member(s) in last 14 days have not interacted or lived with someone who has tested positive for COVID -19.
I Confirm YesNo
B) I am not showing any signs of one or more of the following symptoms. Temperature > 37.3 º C (99.14 º F) or higher, cough, shortness of breath, difficulty breathing, tiredness?
C) I will ensure to use required PPEs and maintain social distancing for prevention of spread of corona virus infection.
I hereby declare that the above statement and information are correct to the best of my knowledge and belief.
(Signature) Name: Organization Contact No Photo ID Proof No Date: YesI hereby declare that the above statement and information are correct to the best of my knowledge and belief.
