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Medical Form - Self Declaration Format 0

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234 views

Medical Form - Self Declaration Format 0

Uploaded by

abhay
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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ANNEXURE 2

Pre-Employment Medical Self-Declaration Form

I hereby declare that the information provided below is true and correct to the best of my
knowledge and understanding. I also confirm that I understand this self-declaration is not in
lieu of the organisation’s Pre-employment Medical Check requirements, but is a process
instituted for a temporary situation arising out of COVID-19 pandemic. I further understand
and accept that I will need to go through a complete Medical Check-up as per the
organisation’s norms post joining once the situation normalises and that the continuation of
my employment is subject to my clearing the same.

ASHISH RANJAN
(Signature of the Prospective Employee)

(Please √ Mark Where Applicable)


1 PERSONAL DETAILS:

First Name: MR. ASHISH Middle Name Surname RANJAN

Address: C/O AMAR NATH, SUGARI DIH, CHAK SAMBHUA, SITAMARHI, BIHAR

City SITAMARHI Pin: 843117

Birth Place: BIHAR Birth Date (dd/mm/yyyy) 16-12-2000

For post applied FASHION CONSULTANT Marital Status: Married / Unmarried Gender M/F

2 PERSONAL HISTORY: Yes No


Are you in good health and capable of full work YES
Have you ever suffered from an occupational disease or injury? YES

Have you ever been discharged or rejected on medical grounds? YES

Types of Previous Occupation (Pl. describe in brief about company, nature of work, duration in years)
Have you ever suffered from any of the following (Answer Yes or No. if yes, give details)

Y N Y N
N Heart disease N Hypertension
N Diabetes N Chronic abdominal /digestive disorder
N Kidney disease N Hepatitis-B
N Asthma N Chronic lung disease (e.g. bronchitis,
pleurisy, pneumonia etc.)
N Tuberculosis N Malaria / Typhoid fever in last 6 months
N Dermatitis or any skin disease N Venereal or Sexually Transmitted Disease
N Epilepsy, Fits, fainting or dizziness N Nervous/Mental disease of any kind
N Any allergy N Any chronic ear or hearing problem (e.g.
sinusitis, rhinitis, otitis etc.)
N Any major operation or injury N Any other illnesses
N Do you have any physical handicap?

Details of any of above if "Yes"

(For female candidates only) Are you pregnant at present? Y N Date of L.M.P.

1. Have you or family member has history of Fever with Cough/ Cold since last two weeks?

A) Yes B) No ✓

2. Have you or family member has history of Fever with Difficulty in breathing since last two

weeks?

A) Yes ✓B) No

3. Have you or family member recently done international travel in last 14 days?

A) Yes ✓B) No

4. Have you or family member has history of contact with Corona virus (COVID-19) patient?

A) Yes ✓B) No

I certify that the information that I have provided is correct and I authorize Reliance Retail to use

it.

I declare that the above statements are true and complete to the best of my knowledge and belief.

Date (dd/mm/yyyy) Signature of Prospective Employee


30-09-2024 ASHISH RANJAN

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