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Personal Details

Your Full Name*
Employee ID*
Contact No.*
Residential Address*
Residential Ward Name and No.*
Is your Residential Area under Seal Down?
 Yes No Don't Know

Medical Details

Have you experienced any of the following symptoms / suffering from any of the symptoms since the last 21 days?*
 Fever Cold Sore Throat Body Ache Dry Cough Diarrhoea Runny Nose Difficulty Breathing Nasal Congestion Non of Above
Do you suffer from any other following pre-existing conditions?*
 Diabetes Hypertension Heart Disease Lung Disease Non of Above

Interaction Details

Have you had any contact with any person who has been diagnosed with COVID 19 in the last 21 days?*
 Yes No Don't Know
Have you had any contact with any person who has been returned from abroad in the last 21 days?*
 Yes No Don't Know
Has any of your family member / neighbour diagnosed with COVID 19 or kept under isolation in the last 21 days?*
 Yes No Don'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.