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COVID - 19 Student Self Declaration Form

The document is a student self-declaration form regarding COVID-19. It requires students to declare if they have tested positive for COVID-19, experienced symptoms, visited high-risk areas, or been in contact with someone with COVID-19. It also requires students to agree to safety protocols like wearing a mask and monitoring temperature while on campus.

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Chandrasree
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9 views

COVID - 19 Student Self Declaration Form

The document is a student self-declaration form regarding COVID-19. It requires students to declare if they have tested positive for COVID-19, experienced symptoms, visited high-risk areas, or been in contact with someone with COVID-19. It also requires students to agree to safety protocols like wearing a mask and monitoring temperature while on campus.

Uploaded by

Chandrasree
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Student Self-Declaration

Declaration Form Regarding COVID – 19


1. Name of the Student :

2. Roll number : Branch / Year / Semester:

3. Address for communication:

Student Mobile No: _______________ parent Mobile No: ____________________


Mail Id:___________________________________________________
4. I, , S/o
hereby declare as follows:

I HAVE NOT:
a) been tested positive or presumptively positive for COVID19 in the last 6 months,

b) experienced any symptoms commonly associated with the COVID19 such as Fever, Cough. Shortness of
breath, Runny nose, Headache, Sore throat, etc.,

c) been to any location designated as hazardous and/or potentially infected with the Coronavirus by a
recognized health or regulatory authority,

d) visited a country in the last 6 months for which the Centre for Disease Control and Prevention (“CDC”) had
issued a Level 3 Travel Advisory for COVID19

e) been in direct contact with or in the immediate vicinity of any person I knew and/or now I know to be
carrying the Coronavirus
rus or has been identified as a potential carrier of the Coronavirus.

5. I AGREE to notify SICET immediately of any change in my health status, including diagnosis with Coronavirus
and/or quarantine, if any,

6. I WILL always wear a mask and I consent to having my temperature recorded by any representative of SICET at
all times while in college premises. I undertake to wash my hands or use sanitizer as mandated by SICET. I will
also provide any follow up information pertaining to COVID19 requested by the college authorities.

7. I declare below the list of countries/cities / places I have travelled to and from Hyderabad since 14 March 2020
prior to arriving at SICET. I am also specifying below the type of zones (red or yellow or green) I resided in the
last 60 days.

 Name of Country/City/ Village I travelled:


 Date of arrival there
 Date of departure from there
 Name of the area / place I resided in the last 60 days and the type of zone is given below.

8. I undertake to pay the tuition fee and other fees on time as per the directions of the institution and as specified at
the time of my admission.
Declared by me this day of month of the year 2020.

Signature of student
Name:

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