Self Declaration Form/Health Screening Form
IIT Indore
Email Address *
Name *
Roll Number/Employee Id
Department *
Head of department/Section *
Contact Number *
Did you suffer from/ tested positive for COVID 19 infection? *
If Yes, When? Give details.
Was any of your family members tested positive for COVID 19 infection? *
If Yes, When? Give details.
Were / Are you in close contact with any positive or suspected case of Covid19? *
If Yes, Give details.
Did / Do any of your family members has close contact with a positive or suspected patient of Covid19? *
If Yes, Give details.
Were you isolated or quarantined by COVID 19 team? *
If Yes, when? Give details.
Was any of your family member isolated or quarantined by COVID 19 team? *
If Yes, when? Give details.
Are you suffering from any of the following symptoms? *
Yes
No
Fever
Cough
Difficulty in Breathing
Sore throat /Running nose
Headache and Malaise
Is any of your family member suffering from: *
Yes
No
Fever
Cough
Difficulty in Breathing
Sore throat/Running nose
Headache and Malaise
Are you suffering from any chronic illness like Diabetes Mellitus, Hypertension, Heart disease etc or on immunosuppressant drugs? *
If Yes, Provide details
Are you presently staying at a location which is the containment zone of COVID 19? *
Did you have a history of travel outside in the last 4 weeks? *
If Yes, From Where? any history of contact with a suspected /a positive case of COVID 19 during this travel?
Did you suffer from any psychological problem in the last 4 weeks? *
If Yes, Please give details
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