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+968-26895100 +968-26895111 PO Box 692, Barka, Oman

Self Declaration Form

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

1. Are you presently suffering from any of the symptoms listed below ?

2. Did you come in contact "within 2 meters" with any confirmed, suspected or quarantined person with new novel coronavirus (COVID-19) in the past 14 days ?

3. Have you been requested for self-isolation by medical Doctor / Authority?

4. Are you fit to Work?

People of any age with any of the following conditions are at increased risk of severe illness from COVID-19 and need to take extra precautions. Contact your line manager for further instructions.

(Serious heart conditions, Chronic lung disease, Chronic Kidney disease, Chronic Liver disease, Cancer Patient, Pregnancy, Chronic condition, uncontrolled blood pressure, uncontrolled Diabetes, obesity).

I, (My name mentioned below) acknowledge that the above information is correct, and I do accept the consequences on false information.

Employee Details :

Employee ID (Example:STO0xxx)

Employee Name

Employee Email ID

Branch

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Welcome to STOMO

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CONTACT US
PO Box 692, Postal Code 320,Barka,Sultanate of Oman
(+968) 26895100 / 26895101
(+968) 26895111