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COVID-–-19-Student-Self-Declaration-Form-converted

The document is a Student Self-Declaration Form regarding COVID-19, requiring students to declare their health status and travel history related to the virus. Students must confirm they have not tested positive for COVID-19, experienced symptoms, or traveled to high-risk areas in the last six months. Additionally, they agree to follow health protocols and notify the institution of any changes in their health status.

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nagssara
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18 views

COVID-–-19-Student-Self-Declaration-Form-converted

The document is a Student Self-Declaration Form regarding COVID-19, requiring students to declare their health status and travel history related to the virus. Students must confirm they have not tested positive for COVID-19, experienced symptoms, or traveled to high-risk areas in the last six months. Additionally, they agree to follow health protocols and notify the institution of any changes in their health status.

Uploaded by

nagssara
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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Student Self-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 or has b en 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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