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Self-Health Declaration Form

This self-health declaration form collects information such as name, arrival date, contact details, age, residence, arrival location, and history of chronic illness from individuals arriving at IIM Ahmedabad. It requires the individual to declare that they have not resided in a containment zone, experienced COVID-19 symptoms, or been under quarantine. The form must be signed and submitted to security@iima.ac.in.

Uploaded by

JAY BHAVIN SHETH (B14EE014)
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38 views1 page

Self-Health Declaration Form

This self-health declaration form collects information such as name, arrival date, contact details, age, residence, arrival location, and history of chronic illness from individuals arriving at IIM Ahmedabad. It requires the individual to declare that they have not resided in a containment zone, experienced COVID-19 symptoms, or been under quarantine. The form must be signed and submitted to security@iima.ac.in.

Uploaded by

JAY BHAVIN SHETH (B14EE014)
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Please e-mail this page to – security@[Link].

in

Self-health declaration form


Name of the arriving person :

Arrived on (Date) :

Mobile No :

Email Id :

Age :

House/Dorm/MSH No.
(Where staying on campus) :

Arriving From
(Give complete address) :

History of chronic illness if any : YES ________ NO _________


(Please tick)

(If Yes, Specify) :

I declare that:

1. I was not residing in any containment zone.


2. I am not suffering from any fever, cough, or any respiratory distress in last one
month.
3. I am not under quarantine.
4. If I ever develop any of the above-mentioned symptoms, I will immediately contact
the dispensary of the institute. (Ext. 4777) Mobile: 9825022796.
5. I have not tested COVID-19 positive in the past / I have tested Covid-19 positive on
___________ and recovered completely thereafter. I will adhere to the health
protocol prescribed by the Gujarat State.

Signature: ____________________

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