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Self Declaration Form- FLAME University
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* Indicates required question
Name
*
Your answer
Contact Number
*
Your answer
Email ID
*
Your answer
Visiting On
*
MM
/
DD
/
YYYY
I have not tested COVID 19 Positive in last 60 Days
*
Yes
No
Required
I am not suffering from any cough/fever/respiratory distress
*
Yes
No
Required
I am Vaccinated
Yes
No
I do not reside in containment zone
*
Yes
No
Required
RT PCR ICMR Number
*
Your answer
Test Results
*
Negative
Positive
Awaited
I declare that all the information stated above by me is true to my knowledge.
*
Yes, I declare
Required
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