Self Registration Form

Personal Details
Name:

Surname:

Gender:
Male Female Others

Date Of Birth:

Age:

Mobile Number:

Email Id:

Category:

Nationality:

Count of family member:

Emergency Contact Details:
Name:

Relationship:

Contact Number:

Place Of Stay (In Meghalaya):
District:

Select Urban/Rural
Rural Urban

Select Municipal Board/Town Committee

Block:

Village/Town:

Locality:

Address:

Arrival in Meghalaya Details:
Arrived From:

Date of Arrival:

Mode of Travel:

Flight No/Vehicle No.:

Seat No.:

Departure Plan


Travel History in the past 14 Days:
Please provide the details of Travel History in the past 14 Days.
Date Start Details End Details Mode of Travel Duration of
stay( in days)
Travel Type Place Travel Type Place
Additional Information:
A. Have you visited any of the Coronavirus disease affected areas in the past 1 Month (Yes/No)
No Yes
B. Do you have any history of contact with any suspected or laboratory confirmed case of Coronavirus disease?(Yes/No)
No Yes

C. If yes, please provide details of where and when the contact happened:


Self Reporting
Symptoms Remarks
Fever
Cough
Fullness of Chest
Breathing Problem
Bodyache
Tiredness
Sore Throat
Self Isolation