Cyient-BCP - PandemicEvent - Annexure-6 - Candidate Declaration Form

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HP-048-BCPP | Business Continuity Plan For Pandemic Events | Version No. 1.0 | Eff.

Date: 2nd Mar 2020

Annexure-6
Self-Declaration Form for Candidates (Candidates attending Interviews /
New Joiners)
Personal contact number (Mobile
Name of Candidate:
number/Home):

Recruiter Name: Nationality (for foreigner only):

Reporting Venue:

Recorded by Cyient staff (name):

Self-declaration by Candidate:

1 If you have the following symptom(s), please tick the relevant box(es)

Fever Drycough Body aches Headaches

Sore throat Runny nose Tiredness Shortness of breath


Others

2 Have you been in contact with a confirmed coronavirus (COVID19) patient in the past
4 weeks?

Yes No

3 Have you been to any of the affected countries in the past 4 months?

Yes No

If yes, please indicate the affected country(s) visited:

4 Travel history (over the last 4 months):

Countries/ City visited:

5 Flights taken: (please mention each leg of the journey)

6 Any of your Family/ Colleagues or acquaintances travelled to any country and returned in the
last 4 months?

Yes No

If yes, please indicate the Country / Cities traveled:

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HP-048-BCPP | Business Continuity Plan For Pandemic Events | Version No. 1.0 | Eff. Date: 2nd Mar 2020

To be filled by New Joiners only:

Candidate ID: Job Requisition (JR) No.:

Job Title: Band:

Date of Joining (DOJ):

Note: To be filled-in by the candidate at least 3 working days before coming to Cyient. This Form
shall be shared with the Candidates by the respective recruiters. Candidate after entering Cyient
premises on the day of interview / joining should fill this form again and submit to the recruiter.

I confirm that I have reviewed the above information and have filled it accurately and completely.
I know that I can be held responsible for any impact my wrong declaration may have on the
company or its employees.

Signature:_______________ Date: