SBI Life Advisor

Covid Self Declaration

Name

Designation

Employee Code

Gender

Branch

Region

Zone

Contact Number

Emergency Contact Number *

Emergency Contact Name *

1) Are you currently residing in Containment Zone ?

Yes

2) Have you or or someone in family staying with you come in close contact with a COVID-19 patient ?

Yes

3) History of International travel in last 15 days ?

Yes

4) Are you suffering from any chronic medical condition such as diabetes, high BP, heart , kidney disease etc ?

Yes

5) Please state whether you are experiencing any of the following symptoms : ( mandatory selection of yes / no)

Symptoms -

Fever

Yes

Cough

Yes

Shortness Of Breath

Yes

Sore Throat

Yes

6) Any of your family members suffering from any of the above symptoms ?

Yes

I hereby declare that the information shared above is true, complete and correct to the best of my knowledge and belief and I am attending the ch club convention & star league convention at my own risk, I will further also inform the key management of the retail agency channel if I show any of the above symptoms during the period of my stay at goa, during the convention,

I hereby also confirm that I have downloaded the arogya setu app on my mobile phone and my location setting as well as blue tooth are always on.

I hereby undertake to fill this online form again if any information in the form regarding my status changes in the interim. I understand that in event of my information being found false, or incorrect at any stage , a disciplinary action or legal action can be taken against me.

I understand that the onus of looking after myself lies with me and I promise to wear a mask in public , to maintain social distancing as per covid guidelines at all times.