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Health Decleration Form

This document is a health declaration form for a student attending UMT. The student declares [1] their current health status including whether they have fever, cough, or difficulty breathing, [2] their willingness to follow all public COVID-19 measures at UMT, [3] their willingness to undergo COVID-19 testing if asked, and [4] their agreement to follow all UMT COVID-19 precautions and instructions. The student signs to affirm that the information provided is true and correct and that they will inform UMT medical authorities of any changes or if the information is misleading.

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ziafat shehzad
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47 views1 page

Health Decleration Form

This document is a health declaration form for a student attending UMT. The student declares [1] their current health status including whether they have fever, cough, or difficulty breathing, [2] their willingness to follow all public COVID-19 measures at UMT, [3] their willingness to undergo COVID-19 testing if asked, and [4] their agreement to follow all UMT COVID-19 precautions and instructions. The student signs to affirm that the information provided is true and correct and that they will inform UMT medical authorities of any changes or if the information is misleading.

Uploaded by

ziafat shehzad
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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ANNEXURE-IV

Health Declaration Form

I, Mr/ Ms _____________________________________ UMT ID No. _____________________


Program____________________Department_______________School/Institute______________
dated _______ and CNIC No. _____________________________________________________
Address in Pakistan __________________________________________________________
Mobile Phone No ___________________________ do hereby solemnly affirms, declares and
undertake:

1) That my health status is as follows (Encircle the relevant one):


i. Fever YES NO
ii. Cough YES NO
iii. Difficulty in Breathing YES NO
2) That I am willing to follow all public measures adopted at the UMT for anti-COVID-19/
coronavirus.
3) That I am willing to undergo all processes applicable for COVID-19/ Coronavirus testing
whenever asked by UMT officials
4) To comply with all anti-COVID-19/ Corona Virus precautionary measures/ instructions
of the UMT authorities.
5) I hereby declare that the details furnished above are true and correct to the best of my
knowledge and belief, and I undertake to inform the concerned UMT Medical Health
Unit regarding any changes therein, immediately. In case any of the above information is
false or untrue or misleading or misrepresenting, I am aware that I may be held liable for
all applicable law(s) of Pakistan.

(_____________________)
Signature

Date: _____________

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