COVID - Certificate of Undertaking on self-isolation for Home Quarantine

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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