ANNEXURE 2
Pre-Employment Medical Self-Declaration Form
I hereby declare that the information provided below is true and correct to the best of my
knowledge and understanding. I also confirm that I understand this self-declaration is not in
lieu of the organisation’s Pre-employment Medical Check requirements, but is a process
instituted for a temporary situation arising out of COVID-19 pandemic. I further understand
and accept that I will need to go through a complete Medical Check-up as per the
organisation’s norms post joining once the situation normalises and that the continuation of
my employment is subject to my clearing the same.
_________________________________
(Signature of the Prospective Employee)
(Please √ Mark Where Applicable)
1 PERSONAL DETAILS:
First Name Middle Name Surname
Address:
City Pin:
Birth Place: Birth Date ( dd/mm/yyyy)
For post applied Marital Status: Married / Unmarried Gender M/F
2 PERSONAL HISTORY: Yes No
Are you in good health and capable of full work
Have you ever suffered from an occupational disease or injury?
Have you ever been discharged or rejected on medical grounds?
Types of Previous Occupation (Pl. describe in brief about company, nature of work, duration in years)
Have you ever suffered from any of the following (Answer Yes or No. if yes, give details)
Y N Y N
Heart disease Hypertension
Diabetes Chronic abdominal /digestive disorder
Kidney disease Hepatitis-B
Asthma Chronic lung disease (e.g. bronchitis,
pleurisy, pneumonia etc.)
Tuberculosis Malaria / Typhoid fever in last 6 months
Dermatitis or any skin disease Venereal or Sexually Transmitted Disease
Epilepsy, Fits, fainting or dizziness Nervous/Mental disease of any kind
Any allergy Any chronic ear or hearing problem (e.g.
sinusitis, rhinitis, otitis etc.)
Any major operation or injury Any other illnesses
Do you have any physical handicap?
Details of any of above if "Yes"
(For female candidates only) Are you pregnant at present? Y N Date of L.M.P.
1. Have you or family member has history of Fever with Cough/ Cold since last two weeks?
A) Yes B) No
2. Have you or family member has history of Fever with Difficulty in breathing since last two
weeks?
A) Yes B) No
3. Have you or family member recently done international travel in last 14 days?
A) Yes B) No
4. Have you or family member has history of contact with Corona virus (COVID-19) patient?
A) Yes B) No
I certify that the information that I have provided is correct and I authorize Reliance Retail to use
it.
I declare that the above statements are true and complete to the best of my knowledge and belief.
Date (dd/mm/yyyy) Signature of Prospective Employee