Mangalam-Self Declaration Form For COVID-19

Mangalam Information Technologies Private Limited - Self-Declaration Form

Note: For the health and safety of our employees, we require you to fill a self-Declaration for yourself, family members and visitors. Please list the following: travel history, illness or any other medical condition for the above stated. All employees / visitors visiting MANGALAM premises need to fill and date the self-declaration form EVERYDAY. MANGALAM reserves right to DENY access after reviewing the completed form.

First Name * Last Name * Employee Code * Department

Joining office after work from home up to 7 days ?
Yes
No

(*) Mandatory

Have you travelled abroad/out of the Ahmedabad during last month?

Travelled abroad Last Month outside Ahmedabad with in 7 days?*
Yes No

Antigen test carried out before joining duty?*
Yes No

Are you coming from contentment zone?*
Yes No

Have you or anyone living with you or near you been in contact with a COVID-19 patient or a suspect in the last 7 days?*
Yes No

If Yes, please mention your last contact date with the person.

Please answer (Tick) the following questions about your personal health:

Please answer the following questions about your personal health*:

Particulars	Yes	No
Fever
Cough
Shortness of Breath
Persistent Pain in the Chest
Sore Throat
Others

If Others, Please Specify below

In vaccination Status -Dese?
Not Yet Taken 1st dose only Both 1st and 2nd dose

Acknowledgement *

I acknowledge that the information I have given is accurate and complete. I know that to swear a false declaration is a crime under the law and with such knowledge only I have sworn for above stated.

Mangalam-Self Declaration Form For COVID-19

Mangalam Information Technologies Private Limited - Self-Declaration Form

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