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HU COVID-19 Health Declaration Form

This document is a health declaration form from The Hajvery University requiring students to provide personal details and declare whether they have experienced any COVID-19 symptoms or potential exposures in the last 14 days. Students must confirm they have not been diagnosed with COVID-19, had a fever or respiratory symptoms, come into contact with COVID-19 cases, or taken fever medication. By signing, students accept responsibility to not come to campus if experiencing any listed situations before arriving and acknowledge they could spread COVID-19.

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Farhan Dogar
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93 views1 page

HU COVID-19 Health Declaration Form

This document is a health declaration form from The Hajvery University requiring students to provide personal details and declare whether they have experienced any COVID-19 symptoms or potential exposures in the last 14 days. Students must confirm they have not been diagnosed with COVID-19, had a fever or respiratory symptoms, come into contact with COVID-19 cases, or taken fever medication. By signing, students accept responsibility to not come to campus if experiencing any listed situations before arriving and acknowledge they could spread COVID-19.

Uploaded by

Farhan Dogar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

THE HAJVERY UNIVERSITY, LAHORE

“HU COVID-19 Health Declaration Proforma”

Full Name ___________________________


CNIC No ___________________________
Gender (Male/Female) ___________________________
Registration No ___________________________
Email address ___________________________
Phone Number ___________________________
Phone Number (Parents/Guardian) ___________________________
Program ___________________________
Semester ___________________________
City of Current Residence ___________________________
City of Permanent Residence ___________________________

I hereby declare that I have had none of the following situations during the last 14 days
immediately preceding the date on this Health Declaration Form:
1. Being confirmed or suspected of COVID-19 infection by any medical institution;
2. Running a fever at or above 37.3ºC or showing respiratory symptoms;
3. Coming into contact with confirmed or suspected COVID-19 cases;
4. Coming into contact with patients with a fever or respiratory symptoms;
5. Staying in a community or hotel reporting confirmed or suspected COVID-19 cases;
6. At least two persons in my family running a fever or showing respiratory symptoms;
7. Taking medicine for fever or cold.
8. Visiting public spaces like hospitals, theaters, restaurants and leisure facilities or taking
part in group activities without taking protective measures like wearing a mask.

I declare the truthfulness and genuineness of the statements above and the COVID-19 negative
affidavit I have provided. If any of the above-mentioned situations happens to me before coming
to campus, I shall not come. I acknowledge and accept the responsibilities under this Declaration
form that might cause the spread of COVID-19.

Signature: ____________________ Date: ____/____/_____


(Day/Month/Year)

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