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Covid19 - Employee Declaration Form-2798

V. Veerendra Reddy completed a COVID-19 employee self-declaration form for his employer. He indicated that he had traveled to his native place DIDUGU(V),(NATIVE PLACE) from June 7-October 12 and obtained prior permission. He answered no to all questions regarding COVID-19 symptoms or exposure. He declared the information as true and understood he would be responsible for any false declarations.

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Veerendra Reddy Vintha
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95 views2 pages

Covid19 - Employee Declaration Form-2798

V. Veerendra Reddy completed a COVID-19 employee self-declaration form for his employer. He indicated that he had traveled to his native place DIDUGU(V),(NATIVE PLACE) from June 7-October 12 and obtained prior permission. He answered no to all questions regarding COVID-19 symptoms or exposure. He declared the information as true and understood he would be responsible for any false declarations.

Uploaded by

Veerendra Reddy Vintha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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COVID-19 EMPLOYEE SELF DECLARATION FORM

1. Do you live in a containment zone? No


2. Have you been outside Hyderabad in the past 2 YES
weeks?
If Yes, please furnish details below:
06/07/2020
i) Date of leaving station
ii) Place(s) visited/stayed DIDUGU(V),(NATIVE PLACE)
iii) Mode of Travel
PERSONNEL CAR
iv) Date of return 12/10/2020
v) Was prior permission obtained from Manager /
YES
Team Lead

3a. Did you attend any social/religious/neighborhood No


gathering with more than 10 people in the past 2
weeks week? If yes, furnish the details (date &
occasion)
3b. Are any such events planned in the next If yes, furnish No
the details (date & occasion)
4. Do you have any family member who is working in No
Essential Services such as Police/ Hospitals / Retail
Store?
5. In the last 14 days/currently are you experiencing any
of the following symptoms?
No
Fever, Cough, Sore Throat
No
Shortness of Breath/Difficulty in Breathing No
Persistent Pain in the Chest No
Loss in Taste and Smell No

If yes, date when the symptoms first appeared. No

6. Have you been in contact with anyone who is No


suspected or diagnosed positive of COVID-19?
If yes, when and how? Have you been screened for
COVID-19?

7. Is anyone in your Residential vicinity infected with No


COVID-19?

I, VEERENDRA REDDY VINTHA hereby declare that the above information is true and factual. I also
understand that if any of the above declarations are found to be false, I am personally responsible for the
consequences. However, Aarvee can take any action deemed fit as per prevailing government issued
guidelines or acts.
(Signature & Date)
Name & E. Code: V.VEERENDRA REDDY,2798
Mobile No.: 9700420317
Current Address: MIG-3,BALAJI NAGAR,KUKATPALLY-500072
If any of the above are Yes, bring it to the notice of your division head, and you should not come to the
office.
If any of the above are Yes, bring it to the notice of your division head, and you should not come to the
office.

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