Coronavirus COVID-19 Self-Declaration Form

  • Coronavirus COVID-19 Self Declaration Form

  • Have you been in any overseas countries in the last 15 days or  are you coming from any overseas airport?
  • In the last 15 days, have you had contacts with someone who  has been in overseas countries affected and had symptoms  such as cough and / or fever?
  • Have you had any of the following symptoms in the past 15  days?  - Temperature rise above 37.2 °
  • Cough
  • Worsening of general physical conditions

  • I hereby undertake to inform if, in the next few days, I find any health problems related to "Coronavirus - Covid 19", so that the company can carry out further checks with the people I met.

  • Date

  • Signature

  • Should be Empty: