COVID-19 Pre-Entry Questionnaire

Please respond to all questions to the best of your knowledge.

1. Have you experienced any COVID-19 symptoms in the last 15 days?

Yes             No

Click all applicable COVID-19 symptoms

Fever

Breathing Difficulty

Dry Cough

Loss of sense of smell / taste

Other Symptoms (please provide details below)

2. Please provide the addresses where you have stayed in the last 15 days
Press + button to add a second address

State/UT Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadra and Nagar Haveli and Daman and Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Ladakh Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha (Orissa) Puducherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal

Address 2

State/UT Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadra and Nagar Haveli and Daman and Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Ladakh Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha (Orissa) Puducherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal

Address 3

State/UT Andaman and Nicobar Islands Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadra and Nagar Haveli and Daman and Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Ladakh Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha (Orissa) Puducherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal

3. Have you or members of your household travelled out of Mumbai the last 15 days?

Yes             No

Travelled from Mumbai to

No of co-travellers 0 1 2 3 4 5 6 7 8 8+

Travel Dates

Mode of Transportation

Personal Vehicle

Private Taxi / Aggregator

Flight

Public Transport (Train / Bus)

Other (please provide details

4. What is the nature of work to be done at HBCSE? (you may select more than one option)

Office Work (ONLY Computer Use)

Office Work (File Handling)

Meetings

Maintenance (Laboratory / Equipments)

Canteen-Related Work

Cleaning (includes washrooms, office and hostel buildings, internal roads)

Waste Management

Gardening

Security

Routine Inspection

Other (provide details)

5. Which rooms / spaces in HBCSE will you be accessing?
(Please select the building(s) and specify the room number(s) that you plan to use)

Main Building (excluding Canteen)

Canteen

NIUS Building

NIUS Hostel

Olympiad Building

Gardens and Lawns

Old Guest House

Other (provide details)

6. Please provide names of all people (if any) who you will be meeting in person at HBCSE, as part of your work.

7. Pick the dates in which you are planning to come to HBCSE

Pick any number of dates within the next 14 days

8. How will you travel to HBCSE?

Personal Vehicle

Private Taxi / Aggregator

Public Taxi / Rickshaw

Public Transport (Train / Bus)

Walking / Cycling

Other (please provide details