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Tick/circle The Appropriate Answers For All Listed

This document is a self-declaration form for hotel guests regarding COVID-19. It requests guests provide their personal details, health status, and recent travel history. Guests must confirm they are not experiencing COVID-19 symptoms and have not been exposed to the virus through contact with infected individuals or travel to contaminated areas within the last 14 days. The form aims to screen guests and allow only asymptomatic individuals on hotel premises to protect guest and staff health and safety during the pandemic.

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Riya Singla
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44 views

Tick/circle The Appropriate Answers For All Listed

This document is a self-declaration form for hotel guests regarding COVID-19. It requests guests provide their personal details, health status, and recent travel history. Guests must confirm they are not experiencing COVID-19 symptoms and have not been exposed to the virus through contact with infected individuals or travel to contaminated areas within the last 14 days. The form aims to screen guests and allow only asymptomatic individuals on hotel premises to protect guest and staff health and safety during the pandemic.

Uploaded by

Riya Singla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SELF-DECLARATION FORM FOR GUESTS (COVID-19)

Dear Valued Guest,

The outbreak of COVID-19 (Novel Coronavirus) requires early and effective detection of suspected cases to
limit the risk of exposure to others. The Ministry of Health and Family Welfare has directed the Hotels to
obtain personnel particulars requested in this form, conducting temperature screenings, and ensuring that
only asymptomatic persons are allowed into hotel premises.

Accordingly, we seek your cooperation in completing this form before you Check-In. We are grateful for your
support and apologize for any inconvenience caused. Please be rest assured that the information collected in
this questionnaire shall be disclosed and used solely for determining whether it is permissible for guests to
stay or use services at the Hotel, to ensure that we provide a safe and healthy environment for everyone
during this period, and as may be permitted by applicable law or required by government and regulatory
authorities.

Name: Place of residence:

Telephone No.: Mobile No.:

Travelling from: Proceeding to:

Check in date: Check out date:

Tick/circle the appropriate answers for all listed

1. Do you currently have any of the following symptoms?

Fever/Chills YES / NO Cough YES / NO

Shortness of Breath YES / NO Difficulty breathing YES / NO

Sore Throat YES / NO Diarrhoea YES / NO

Others YES / NO

2. Within the pa st 1 4 da ys ha ve you,

(i) Expe r ie nce d a ny of the ab ove symptoms ? YES / NO

YES / NO
(ii)Come in contact with any person/s who was tested COVID-19 Positive on or within 14
days of your contact with them?

(iii)Travelled outside India in the last 14 days? YES / NO

YES / NO
(iv)Visited any area within India / State / City, in a contamination zone or in any place
which was declared contaminated during or after your visit?
4. Are you currently on medication for any of the below: YES / NO
Hypertension, Diabetes, Asthma, Cancer

or any other illness or condition, please indicate

I hereby confirm that the information contained in this Self-Declaration Form is accurate and complete.

Name: Signature & Date:

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