UNDERTAKING BY COVID-19 PATIENT FOR HOME ISOLATION
District Task Force for Covid-19 Kohima
1. Is your request for home isolation in full knowledge of your family members, village council / Urban local body? *
2.Following facilities should be mandatorily available at your home. *
Yes
No
a.Single room with proper ventilation with an attached bathroom?
b.Dedicated young and healthy caregiver available for 24x7?
c. Facility for communication available?
d. Do you have sufficient quantities of masks and hand gloves?
e. Appropriate disinfectants in sufficient quantity available?
f. Fingertip pulse oximeter and thermometer available?
3. Check the box(s) if you have any of the following related problems. *
Required
4. I do hereby voluntarily undertake to maintain strict self-isolation and follow the guidelines of Home Isolation at all times throughout the prescribed period.
5. I shall monitor my own health and regularly inform my health status to the District Surveillance Officer (DSO) for further follow up by the Surveillance Team.
6. I shall contact the District Task Force (DTF) and or call the toll free State Health Helpline 18003450019 incase I suffer from any deteriorating symptoms or any of close family contacts develops any symptoms consistent with COVID-19.
7. If any complication arises out of my non-disclosure, I shall be held solely responsible.
8. For any act of commission or omission or breach of the guidelines on Home Isolation, I shall be liable for punishment as per the provision of the Nagaland Epidemic Disease within (COVID-19) Regulations, 2020 under the Epidemic Disease Act 1897.
9. In the event of non-compliance of the mandatory requirement of the guidelines as stipulated as per the SOP formulated by the government, I will not be eligible for the Home Isolation.
10. I have read all the points given in Sl. No. 4-9 above and agreed to comply. *
I, the undersigned in sound mind and to the best of my knowledge, do hereby declared the above mentioned requisite information for consideration of Home Isolation.
Your Full Name. *
Father Name. *
House No. *
Name of Ward/Colony/Village. *
District. *
Contact Number/Alternate Contact number *
Date. *
MM
/
DD
/
YYYY
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