Self-Disclosure by Contractor Employees [COVID-19]

Kindly answer the following questions, fill in the contact details and sign this disclosure form.

Question 1: Did you or any of your first-degree relatives or domestic helpers come to Oman in the last 14 days?
[ ] Yes [ X ] No
If answer to question is YES then mention the countries and dates of visit:
Countries visited or transited Date of Arrival in Oman Employee/Relationship

Question 2: Did you come in contact with any confirmed, suspected or quarantined person with new novel
coronavirus (COVID-19)?
[ ] Yes [ X ] No
If answer to question is YES then: Date of contact ____/____/____ Where: __________________________________

Question 3: Are you presently suffering from any of the symptoms listed below?
Symptoms: fever with acute onset and/or cough with acute onset and/or shortness of breath, and/or diarrhea
and/or sore throat, and/or runny nose.
[ ] Yes [ X ] No If answer to question is YES then:
Which symptom(s): ____________________________________ For how many days:
__________________________

Question 4: Are you staying in a lockdown area?

[ ] Yes [ X ] No If answer to question is YES then: Location:
__________________________________
Question 5 - Are you presently suffering from any health condition that put you at higher risk of serious illness?
[ ] Yes [ X ] No If answer to question is YES then:
Which health condition: [ ] Cardiac problems / [ ] Uncontrolled Blood Pressure / [ ] Uncontrolled Diabetes [ ]
Age more than (65) +/- chronic conditions / [ ] Cancer patient / [ ] Chronic respiratory conditions (Asthma) / [ ]
Immunosuppressive treatment / [ ] Pregnancy

If you or first-degree relative family member or domestic helpers are currently in Oman, with past-recent history
of travel and have developed acute respiratory infection (sudden onset of at least one of the following: fever,
cough, shortness of breath), you shall cease coming to office/plant and immediately communicate with your line
manager and company focal point.
I, (My name mentioned below) acknowledge that the above information is correct, and I do accept the consequences on false
information.
Employee Name: Mohamed Ansar Ali Signature:
Employee ID #: W67588
Location: SAP
Manager: Stephane Bos Employee Contact: 97135888

OQ – Occupational Health Department

COVID-19 Self-Declaration Form by Contractor Employees - Form review: 05—14/05/2020
 OQ Contract Holder Name: Mazin Al Blushi Date: 5/12/2020

OQ – Occupational Health Department

COVID-19 Self-Declaration Form by Contractor Employees - Form review: 05—14/05/2020