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Self Declaration Health Form

This self-declaration health form requires travelers to confirm that they are not residing in a containment zone, experiencing any COVID-19 symptoms, or under quarantine. It also requires them to provide contact information, agree to contact health authorities if symptoms develop, confirm they have not tested positive for COVID-19 in the last three weeks, and acknowledge they could face penalties for traveling if ineligible.

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rakesh kumar
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522 views1 page

Self Declaration Health Form

This self-declaration health form requires travelers to confirm that they are not residing in a containment zone, experiencing any COVID-19 symptoms, or under quarantine. It also requires them to provide contact information, agree to contact health authorities if symptoms develop, confirm they have not tested positive for COVID-19 in the last three weeks, and acknowledge they could face penalties for traveling if ineligible.

Uploaded by

rakesh kumar
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 HEALTH FORM

It is mandatory, as per the Government of India guidelines,


to give a declaration to the following effect:

i) I/we am/are not residing in any containment zone.


ii) I/we am/are not are suffering from
any fever/cough/any respiratory
distress.
iii) I/we am/are not under quarantine.
iv) If I/we develop any of the above-mentioned symptoms. I
shall contact the concerned health authorities immediately.
v) I/we have not tested COVID-19 positive in the last three weeks.
vi) I/we am/are eligible to travel as per the extant norms.
vii) I shall make my mobile number/contact details available to
the airlines whenever required by them.
viii) I understand that if I undertake the air journey without
meeting the eligibility criteria, I would be liable to penal action.
Ix) I am/we are fully aware of the state requirements.

Name(s): Sakshi Srivastava


PNR number: E6UH5F
Flight number: SG8477 Seat number: 24 A
Destination:
Origin: DELHI(DEL)
GORAKHPUR(GOP)

Mobile number: 7007196640

E-mail ID: sakshisrivastav1725@gmail.com


Address at the destination: Azad chowk, Rustampur, Gorakhpur

Destination pin code: 273016


Signature: Sakshi Srivastava

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