Free Health Declaration Template
Health Declaration
I, [YOUR NAME], currently residing at [YOUR ADDRESS], and an employee at [YOUR COMPANY NAME] within the department of [YOUR DEPARTMENT], hereby certify the following health-related information to the best of my knowledge as required by [YOUR COMPANY NAME] for operational and safety protocols. This declaration is pursuant to the health and safety guidelines enforced by [YOUR COMPANY NAME] in response to health regulations and corporate policy commitments.
I. Personal Information
Full Name: [YOUR NAME]
Address: [YOUR ADDRESS]
Email: [YOUR EMAIL]
Department: [YOUR DEPARTMENT]
Position: [YOUR POSITION]
Contact Number: [YOUR PHONE NUMBER]
II. Health Status Declaration
I confirm that as of [TODAY'S DATE], I have not experienced any symptoms associated with COVID-19, including but not limited to fever, cough, and shortness of breath. Additionally, I have not been diagnosed with COVID-19 within the past 14 days nor have I come into close contact with a confirmed or suspected case of COVID-19. I agree to report promptly to [YOUR COMPANY NAME]'s Human Resources department and my immediate supervisor any signs of symptoms or diagnosis of COVID-19.
III. Recent Travels
I declare that I have not traveled internationally to any high-risk countries as defined by the World Health Organization or any health authorities within the past 14 days from [TODAY'S DATE]. Should any travel occur during the course of my employment, I will adhere to the necessary quarantine protocols as mandated by local and international health advisories before resuming my presence on company premises.
IV. Commitment to Safety
I pledge to continue adhering to all health advisories issued by the local government and health organizations as well as all workplace safety protocols established by [YOUR COMPANY NAME]. This includes regular hand washing, wearing masks, maintaining social distancing within the workplace, and following all directives for hygiene and health safety.
V. Declaration Agreement
By signing this document, I verify that the information provided is true and accurate to the best of my knowledge. I understand that providing false or misleading information can result in disciplinary actions by [YOUR COMPANY NAME] up to and including termination of employment. Furthermore, I commit to updating [YOUR COMPANY NAME] related to any changes in my health status that might affect my colleagues or my work environment.
Signature:
[Your Name]
[Position Title]
[Your Company Name]
Date: [Date]
