Self-Declaration Form - 01-08-2020 - Version - 2.0

COVID-19 Self-Declaration Form
(To be filled by candidates/working personnel)
Full Name of Candidate / Personnel:

Phone Number:
Date of Self Declaration:
Question Yes No
1. Have you visited or returned from any overseas country in the last
45 days? If yes, please specify the country here:
2. Have you visited or returned from any other District or State in the
last 14 days? If yes, please specify the state here:
3. Have you recently interacted or lived with someone who has tested
positive for COVID-19?
4. Have you now, or in the past 72 hours, had any of the following
flu-like symptoms?
● Cough
● Fever
● Difficulty in Breathing
● Loss of senses of smell & taste
● Throat pain
I hereby declare that I am not suppressing any relevant/ material facts and all the above-stated
information is correct to the best of my knowledge. I understand that Non-disclosure/ suppression of
information may attract penal provisions.
I also declare that I have been informed about the COVID-19 safety guidelines and necessary
precautions to be taken as per the directives issued by the Ministry of Home Affairs, Govt. Of India. I
am aware that not following these guidelines is a punishable offence and will be dealt with strictly by
the appropriate authorities.
Therefore, I fully understand and undertake that I will always:

1. Comply with the critical health and safety guidelines and advisory published by the
Government of India and the relevant state government.
2. Download the Aarogya Setu app on my smartphone, register myself on the app and keep
assessing my health to check for COVID-19 infection risk periodically.
Page 1 of 2 Self-Declaration Form_01-08-2020_Version_2.0

3. Share my health status on the Aarogya Setu app at the entry point of my work location. I
understand that my entry to the work location will be denied in the absence of the
Aarogya Setu app on my smartphone and when I am assessed by the app as a risk to
my colleague’s and customer’s health.
4. Promote a safe, healthy workplace and ensure that I take adequate preventive
measures for the safety of colleagues and customers during the COVID-19 pandemic.
5. Follow all health and safety instructions and advisory published by my employer.
6. Attend mandatory awareness sessions including but not limited to the safety briefing,
training and any other forms of communications organized at the workplace.
7. When interacting with customers, colleagues and others outside the facility, I will always
wear a clean and functional face mask and other personal protective equipment as
advised by my employer or client.
8. Maintain social distancing inside and outside the facility.
9. Never consume or spit tobacco, paan, gutka or similar products inside company
premises or in public places as it is a punishable offence.
10. Not smoke cigarettes, beedi or other such products inside the office facility or other
public places as prohibited under law.
11. Not report to work under the influence of illegal drugs or alcohol nor should consume
or poses such intoxicating substances during work hours.
12. Cooperate with safety and security guidelines and follow safety instructions.
13. Wash and sanitize hands frequently when inside the facility and before delivering to
the customer.
14. Be present at the deputed work location only during the duration of my designated shift.
15. Maintain personal hygiene and cleanliness.
16. Consult the doctor and disclose any flu-like symptoms.
I hereby authorize M/s. Instakart Services Pvt Ltd and any Flipkart group company, in accordance
with government guidelines and company policies to collect, record, share and otherwise process
my body temperature reading and other personal information provided by me. This is to help
promote a safe and healthy workplace and safety of co-workers and customers during the COVID-
19 pandemic.
I fully understand and will strictly follow the above health and safety guidelines and any update
thereof as shared by my employer from time to time. I also agree that in case of negligence or failure
to follow these guidelines during my deputation in the client location, my employer will take
necessary disciplinary action including withdrawal or termination of service for breach of contract
with immediate effect.
(Signature)
Full Name:
Date:

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COVID-19 Self-Declaration Form

(To be filled by candidates/working personnel)

Full Name of Candidate / Personnel:

● Loss of senses of smell & taste

Therefore, I fully understand and undertake that I will always:

Page 1 of 2 Self-Declaration Form_01-08-2020_Version_2.0

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