Scribd
Upload
156 views5 pages

Health Screening Form For Employees

The document is a health screening form for employees of a company to prevent the spread of COVID-19. It requests employees to fill out a self-screening questionnaire before coming to work. It lists dos and don'ts for employees related to travel to work, social distancing measures, and health monitoring procedures at the office. Employees must agree to abide by the company's COVID-19 safety policies before being allowed to report to work.

Uploaded by

Arun Mmohanty
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
156 views5 pages

Health Screening Form For Employees

The document is a health screening form for employees of a company to prevent the spread of COVID-19. It requests employees to fill out a self-screening questionnaire before coming to work. It lists dos and don'ts for employees related to travel to work, social distancing measures, and health monitoring procedures at the office. Employees must agree to abide by the company's COVID-19 safety policies before being allowed to report to work.

Uploaded by

Arun Mmohanty
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
You are on page 1/ 5

7/22/2021 Health Screening Form For Employees

Health Screening Form For Employees


To prevent the spread of COVID-19 in our campus and reduce the risk of exposure to our
employees, contractors and visitors, we are requesting you to fill the self screening
questionnaire. Your participation is important to help us take precautionary measures to protect
you and everyone in this campus.

Self Declaration - Please read the section below


Before reaching office

Dos

• Download the Arogya setu app and check if you are in the safe zone

• Measure your body temperature to confirm that you do not have fever

• Travel by the company-provided transport or your own vehicle

• Fill your self-declaration form with travel history, if any

• Wear a mask before reaching office

• Enable digital payment mode in your mobile (Hunger Box, Sodexo, Paytm) to pay at cafeterias and
restrict the use

of physical currency

Don’ts

• Don’t come to office if you are in the risk zone, have traveled to red zones or have come in contact
with anyone

who has tested positive for COVID-19

• Don’t use public transport like buses, trains and taxis

• Don’t bring any unnecessary material or equipment inside the facility.

• Don’t come to office if you are pregnant, sick or suffering from Diabetes/respiratory disorders

After reaching office

Social distancing (6 feet) can help reduce the spread of COVID-19

Dos

• Allow temperature screening by the security, while entering the campus

• Maintain 6 feet (2 meters) social distancing at entry, workstation, cafés, pantry, lifts, and meeting
rooms

https://forms.microsoft.com/Pages/ResponsePage.aspx?id=5MSKJWoUHkGdyHmp4S_W2p96ts9QdnhIqYaNA8No-cJUMkk0NFhNV1Q0TVcxU0NJNj… 1/5
7/22/2021 Health Screening Form For Employees

• Sanitize all IT equipment at the ‘Decontamination desk’ before entering the premises

• Ensure hand hygiene; use hand sanitizer whenever you touch common points

• Wear a mask and dispose of the mask in a closed dustbin only, after use

• Employees who have cough, cold or fever will be checked at the Occupational Health Center
(OHC) if they are in

office

Don’ts

• Avoid close personal contact, such as touching or shaking hands

• Don’t invite visitors or vendors inside the campus.

• Don’t serve yourself in the cafeteria. Wait for the dedicated food handler to serve you

• Strictly avoid going out of the campus for food or hanging around in the cafeterias after meal

• Avoid mass gatherings. Meetings should be restricted to not more than four people; ensure social
distancing during

meetings as well.

1. Please choose the appropriate option *

I am coming to office voluntarily

I have not volunteered to come to office

2. Please select the relevant option *

I am Healthy

I have one of these symptoms - Fever, Dry cough, Body Ache, Headaches, Sore throat,
Runny Nose, Tiredness, Shortness of Breath

3. Download of Aarogya Setu app is required for entry into Wipro Campus. *

I have the Aarogya Setu app

I have not downloaded the Aarogya Setu app

4. Have you been in contact with a confirmed COVID-19 patient in the past 28 Days?
*

Yes
https://forms.microsoft.com/Pages/ResponsePage.aspx?id=5MSKJWoUHkGdyHmp4S_W2p96ts9QdnhIqYaNA8No-cJUMkk0NFhNV1Q0TVcxU0NJNj… 2/5
7/22/2021 Health Screening Form For Employees

No

5. Have you been to COVID-19 affected countries or hot spots inside the country in
the past 28 days? *

Yes

No

6. Declaration : If i have any symptoms like - Fever, Dry cough, Body Ache,
Headaches, Sore throat, Runny Nose, Tiredness, Shortness of Breath or related
symptoms, i will NOT come to office *

Accept

Deny

7. Declaration : I agree to abide by the Social Media Policy of Wipro (For details,
please visit the Social Media Policy in the Suraksha app in myWipro) *

Agree

Deny

8. Have you returned back from any other city, district or state to your work location
during the last 15 days? *

Yes (Please be on home quarantine for 14 days before coming to Wipro Campus)

No

9. Employee Declaration *

I have made the declarations above to the best of my knowledge & accept the
guidelines & policies mentioned above
https://forms.microsoft.com/Pages/ResponsePage.aspx?id=5MSKJWoUHkGdyHmp4S_W2p96ts9QdnhIqYaNA8No-cJUMkk0NFhNV1Q0TVcxU0NJNj… 3/5
7/22/2021 Health Screening Form For Employees

I do not accept the guidelines & policies mentioned above

10. I read and understood the steps taken by Wipro to ensure safety of its employees
and precautionary measures that I need to follow to ensure safety of my
colleagues, family and self. I confirm that I shall report to office. *

Accept

Decline

Employee Details

11. Employee ID *

20142457

12. Personal 10 digit Mobile Contact Number (Do not Prefix +91 or 0) *

9676921145

13. Please enter the 6 digit pin code of your locality *

751002

This content is created by the owner of the form. The data you submit will be sent to the form owner. Microsoft is not
responsible for the privacy or security practices of its customers, including those of this form owner. Never give out your
password.

Powered by Microsoft Forms | Privacy and cookies | Terms of use

https://forms.microsoft.com/Pages/ResponsePage.aspx?id=5MSKJWoUHkGdyHmp4S_W2p96ts9QdnhIqYaNA8No-cJUMkk0NFhNV1Q0TVcxU0NJNj… 4/5
7/22/2021 Health Screening Form For Employees

https://forms.microsoft.com/Pages/ResponsePage.aspx?id=5MSKJWoUHkGdyHmp4S_W2p96ts9QdnhIqYaNA8No-cJUMkk0NFhNV1Q0TVcxU0NJNj… 5/5

You might also like