Is your Residential Area under Seal Down?
YesNoDon't Know
Have you experienced any of the following symptoms / suffering from any of the symptoms since the last 21 days?* FeverColdSore ThroatBody AcheDry CoughDiarrhoeaRunny NoseDifficulty BreathingNasal CongestionNon of Above Do you suffer from any other following pre-existing conditions? DiabetesHypertensionHeart DiseaseLung DiseaseNon of Above
Have you had any contact with any person who has been diagnosed with COVID 19 in the last 21 days?* YesNoDon't Know Have you had any contact with any person who has been returned from abroad in the last 21 days?*YesNoDon't Know Has any of your family member / neighbour diagnosed with COVID 19 or kept under isolation in the last 21 days?* YesNoDon't Know
I hereby declare that all the information furnished above is, to the best of my knowledge, true and correct and that no information has been omitted or withheld. I also further declare that I am fit to resume work at Miracle Electronic Devices Private Limited, and this declaration of readiness is not being made under any duress or stress.
