STOP CORONAVIRUS - REPORT RESPONSIBLY ON COVID-19

SELF DECLARATION FORM

I hereby declare that

A) I/my family member(s) in last 14 days have not interacted or lived with someone who has tested positive for COVID -19.

Yes No

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?

Yes No

C) I will ensure to use required PPEs and maintain social distancing for prevention of spread of corona virus infection.

Yes No

I hereby declare that the above statement and information are correct to the best of my knowledge and belief.

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