COVID-19 SELF DECLERATION FORM

I,………………………..., resident of house no. ……………………………… do hereby, declare the following:

I have read the Instructions, Guidelines and relevant orders of Govt of India pertaining to COVID-19 pandemic. I have read Information Bulletin, Instructions and Notices related to this examination available on the website mait.ac.in.

I have in the last 14 days experienced the following flu-like symptoms   (please tick, wherever it is applicable to you, otherwise leave blank):

Fever: ❏, Cough: ❏, Breathlessness: ❏, Sore throat / Runny Nose: ❏, Body ache: ❏ Others- Please specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _ _ _ _ _ _ _ _ _ _  _ _ _ _

• been in close contact with a confirmed case of COVID-19 ('Close contact' means being at less than one-meter distance for more than 15 minutes.) ❏
• Not been in close contact with a person suffering from COVID-19 and am NOT under mandatory quarantine: ❏
• Travelled the following cities/ country in the last 14 days prior to arriving at the Centre. ❏

        Date & Place                                                                                                                 Name & Signature