Undertaking on self-isolation for COVID Home Quarantine
Undertaking on self-isolation
I ………………………… S/W of ……………………, resident of …………………………………… being diagnosed as a confirmed/suspect case of COVID-19, do hereby voluntarily undertake to maintain strict self-isolation at all times for the prescribed period. During this period, I shall monitor my health and those around me and interact with the assigned surveillance team/with the call center (1075), in case I suffer from any deteriorating symptoms or any of my close family contacts develops any symptoms consistent with COVID-19.
I have been explained in detail about the precautions that I need to follow while I am under self isolation.
I am liable to be acted on under the prescribed law for any non-adherence to self-isolation protocol.
Signature____________________
Date_______________________
Contact Number _____________
Counter signature by Treating Medical Officer
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