Scribd Logo
Upload

Welcome to Scribd!

  • 18 views

    Self Declaration Health Form

    Uploaded by

    Mohanasundaram Kandasamy

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Self Declaration Health Form

    Uploaded by

    Mohanasundaram Kandasamy
    18 views5 pages

    Original Title

    self_declaration_health_form (1)

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views5 pages

    Self Declaration Health Form

    Uploaded by

    Mohanasundaram Kandasamy

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    SELF-DECLARATION HEALTH FORM

    It is mandatory, as per the Government of India guidelines,


    to give a declaration to the following effect:

    i) I/we am/are not residing in any containment zone.


    ii) I/we am/are not are suffering from any
    fever/cough/any respiratory distress.
    iii) I/we am/are not under quarantine.
    iv) If I/we develop any of the above-mentioned symptoms. I shall
    contact the concerned health authorities immediately.
    v) I/we have not tested COVID-19 positive in the last three weeks.
    vi) I/we am/are eligible to travel as per the extant norms.
    vii) I shall make my mobile number/contact details available to the
    airlines whenever required by them.
    viii) I understand that if I undertake the air journey without meeting
    the eligibility criteria, I would be liable to penal action.
    Ix) I am/we are fully aware of the state requirements.

    Name(s):
    PNR number:
    Flight number: Seat number:
    Origin: Destination:

    Mobile number:
    E-mail ID:
    Address at the destination:

    Destination pin code:

    Signature:
    SELF-DECLARATION HEALTH FORM
    It is mandatory, as per the Government of India guidelines,
    to give a declaration to the following effect:

    i) I/we am/are not residing in any containment zone.


    ii) I/we am/are not are suffering from any
    fever/cough/any respiratory distress.
    iii) I/we am/are not under quarantine.
    iv) If I/we develop any of the above-mentioned symptoms. I shall
    contact the concerned health authorities immediately.
    v) I/we have not tested COVID-19 positive in the last three weeks.
    vi) I/we am/are eligible to travel as per the extant norms.
    vii) I shall make my mobile number/contact details available to the
    airlines whenever required by them.
    viii) I understand that if I undertake the air journey without meeting
    the eligibility criteria, I would be liable to penal action.
    Ix) I am/we are fully aware of the state requirements.

    Name(s):
    PNR number:
    Flight number: Seat number:
    Origin: Destination:

    Mobile number:
    E-mail ID:
    Address at the destination:

    Destination pin code:

    Signature:
    SELF-DECLARATION HEALTH FORM
    It is mandatory, as per the Government of India guidelines,
    to give a declaration to the following effect:

    i) I/we am/are not residing in any containment zone.


    ii) I/we am/are not are suffering from any
    fever/cough/any respiratory distress.
    iii) I/we am/are not under quarantine.
    iv) If I/we develop any of the above-mentioned symptoms. I shall
    contact the concerned health authorities immediately.
    v) I/we have not tested COVID-19 positive in the last three weeks.
    vi) I/we am/are eligible to travel as per the extant norms.
    vii) I shall make my mobile number/contact details available to the
    airlines whenever required by them.
    viii) I understand that if I undertake the air journey without meeting
    the eligibility criteria, I would be liable to penal action.
    Ix) I am/we are fully aware of the state requirements.

    Name(s):
    PNR number:
    Flight number: Seat number:
    Origin: Destination:

    Mobile number:
    E-mail ID:
    Address at the destination:

    Destination pin code:

    Signature:
    SELF-DECLARATION HEALTH FORM
    It is mandatory, as per the Government of India guidelines,
    to give a declaration to the following effect:

    i) I/we am/are not residing in any containment zone.


    ii) I/we am/are not are suffering from any
    fever/cough/any respiratory distress.
    iii) I/we am/are not under quarantine.
    iv) If I/we develop any of the above-mentioned symptoms. I shall
    contact the concerned health authorities immediately.
    v) I/we have not tested COVID-19 positive in the last three weeks.
    vi) I/we am/are eligible to travel as per the extant norms.
    vii) I shall make my mobile number/contact details available to the
    airlines whenever required by them.
    viii) I understand that if I undertake the air journey without meeting
    the eligibility criteria, I would be liable to penal action.
    Ix) I am/we are fully aware of the state requirements.

    Name(s):
    PNR number:
    Flight number: Seat number:
    Origin: Destination:

    Mobile number:
    E-mail ID:
    Address at the destination:

    Destination pin code:

    Signature:
    SELF-DECLARATION HEALTH FORM
    It is mandatory, as per the Government of India guidelines,
    to give a declaration to the following effect:

    i) I/we am/are not residing in any containment zone.


    ii) I/we am/are not are suffering from any
    fever/cough/any respiratory distress.
    iii) I/we am/are not under quarantine.
    iv) If I/we develop any of the above-mentioned symptoms. I shall
    contact the concerned health authorities immediately.
    v) I/we have not tested COVID-19 positive in the last three weeks.
    vi) I/we am/are eligible to travel as per the extant norms.
    vii) I shall make my mobile number/contact details available to the
    airlines whenever required by them.
    viii) I understand that if I undertake the air journey without meeting
    the eligibility criteria, I would be liable to penal action.
    Ix) I am/we are fully aware of the state requirements.

    Name(s):
    PNR number:
    Flight number: Seat number:
    Origin: Destination:

    Mobile number:
    E-mail ID:
    Address at the destination:

    Destination pin code:

    Signature:

    You might also like