Health Assessment Form – SLTC Hostel Reservation

Email

1. Name

2. Student ID No.

3. NIC No:

4. Sex

Male

Female

5. Permanent Address

6. Current Address (if different from above)

7. City/Village commuting from at beginning of this journey

8. Were you diagnosed of having COVID-19:

Yes

No

Don't Know

8.1. If yes, Month?

8.2 Year?

9. Have you been vaccinated?

Yes

No

9.1. If Yes,

1st dose

2nd dose

Booster

9.3. If 9 Above is "NO", state reason:

10. Have you got any of the following symptoms?

10.1 Any Other ? Please Specify

11 . Did you, in the past 14 days, come in Close contact* with someone who had Covid-19?

Yes

No

* Close Contact is defined as:

Providing care
Living at the same place
Being in an enclosed environment (workplace/ vehicle/room) for more than 15 minutes
Touching or sharing utensils or personal items

12. Has had flu like symptoms within last 14 days?

Yes

No

13. Have you visited a government/private hospital during past 14 days?

Yes

No

I, the undersigned, declare that the information I have provided is accurate and true. I am
herewith informed that if I provide false information, I could be prosecuted under the
Ordinance of Quarantine and Prevention of Diseases and Chapter XIV on Public Health &
Safety of the Penal Code of Sri Lanka.

I declare that I will abide by all rules and regulations that are set in place for COVID-19
prevention and will always act responsibly ensuring the safety of myself and all others
around me.

I declare that I will disclose without delay or malice any symptoms or indication of sickness
whilst occupying any SLTC facility at the earliest to the management.

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