COVID-19 Self Declaration Form for Crew

COVID-19 Self Declaration Form for Crew

For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Full Name : *

First Name Middle Name Last Name
Sex : *

Male Female Transgender
Age : *
Aadhar Card Number : *
PAN Card : *
Department / Designation :

1) Have you had any of the following symptoms in the last 24 hours? *

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
Decrease or Loss of Taste and/or Smell
Difficulty Swallowing
Runny or Stuffy/Congested Nose
Pink Eye
Digestive issues like Nausea / Vomiting, Diarrhea / Stomach Pain
Extreme Tiredness
Falling Down Often

If you answer “YES” to any of the questions, please DO NOT attend the shoot and post production.

You should:
- Self- quarantine for at least 10 days from the date on which you first experienced any of the above symptoms ; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you: *

	Yes	No
Been in contact with someone who has diagnosed with COVID-19?
Been in close contact with someone who have COVID-19 symptoms ?
Travelled outside of India or taken a cruise

3) In the last 14 days, have you : *

	Yes	No
received a COVID Alert exposure notification on Aarogya Setu App on your cell phone?
been told by a doctor, health care provider, or public health unit that you should currently be isolating (staying at home)?

4) Name(s) of Indian States you travelled in last 14 days (if applicable) :
Contact No. : *

Area Code Phone Number
Email :
example@example.com
Address :

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Declaration and Data Privacy Consent Form :

By signing this form, I declare that the information I have given is true, correct, and complete. I understand that failure to answer any question or giving a false answer can be penalised in accordance with law.

I declare, I will take care of myself (by wearing masks, using Sanitizer frequently, keeping social distance with other team members) during the shoot or till my job period ends on this project. During my job period, if I get tested positive with COVID, I will get quarantined / hospitalised as per the suggestions of doctor / health care provider on my own expences. Company will not be responsible for the loss and I permit company to find and appoint a replacement on my position, till I get recovered.

I also voluntarily and freely consent to the collection and sharing of the above personal information only in relation to Naishtika Audio Visuals' compliance to COVID-19 business operation requirements and in accordance with the Data Privacy Act. For any concerns, you may contact communication@naishtika.com.
Signature : *

Clear
Date & Time : *

Month Day Year
Date Hour Minutes AM/PM Option
Auto human verification : *
If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your doctor or health care professional for recommended next steps.
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