Intraweb

Online Declaration Form, Undertaking - I

Name(*)

Please enter valid name

Email(*)

Invalid Input

Name of Supervisor/Guide/ Reporting Officer.(*)

Invalid Input

Designation(*)

Invalid Input

Mobile No.(*)

Invalid Input

Email of Supervisor or Reporting Officer(*)

Invalid Input

from (Date)	to (Date)	place	Whether the area was red zone / containment area in the last 14 days (Yes / No)
Invalid Input	Invalid Input	Invalid Input Invalid Input Invalid Input	YesNo Invalid Input
Invalid Input	Invalid Input	Invalid Input Invalid Input Invalid Input	YesNo Invalid Input
Invalid Input	Invalid Input	Invalid Input Invalid Input Invalid Input	YesNo Invalid Input

During the lockdown period whether attended office in person, for essential/critical activities?

YesNo Invalid Input

If yes, furnish the date(s) of attending office

Invalid Input

During the lockdown period whether attended official meeting (s) through video conferencing platforms

YesNo Invalid Input

If yes, furnish the date(s) of meeting(s) attended

Invalid Input

Whether Aarogya Setu App has been installed in your mobile.

YesNo Invalid Input

(Aarogya Setu App installation is compulsory and only those with ‘Low risk of infection’ (green signal) will be allowed to enter the office premises/hostel etc.)

Status of health in the last 14 days	Symptoms of cold/cough/throat irritation/fever (Yes / No)	If Yes, Medical check up details and copy of the certificate/Doctor’s prescription etc. to be enclosed
Self	YesNo Invalid Input	Upload only jpg or png image file format of size not more than 400KB Invalid Input
Family Members	YesNo Invalid Input	Upload only jpg or png image file format of size not more than 400KB Invalid Input

Any other information

Invalid Input

I understand that in case the information provided above is found incorrect:

(a) the CeNS Administration has the authority to report the same to the concerned authorities, and that I will be liable for punishment under the rules of the National Disaster Management Act, 2005, Epidemic Diseases Act, 1897 and Indian Penal Code, 1860 and any other penal provisions as the Government may decide from time to time.

(b) I will also be liable for strict disciplinary action as per the norms of the Centre. Invalid Input

Place of embarkation(*) Invalid Input

(*)I am planning to return to Bengaluru tentatively by Date

and therefore seek your permission to travel. Invalid Input

Please enter captcha

Refresh

Invalid Input

Useful Links

Location

Contact

Centre for Nano and Soft Matter Sciences(CeNS)
Arkavathi, Survey No.7,
Shivanapura, Dasanapura Hobli,
Bengaluru - 562162
Phone: +91 (0)80 296 300 89 / 90

Email: censoffice@cens.res.in

Office Hours
Monday to Friday
9:00 AM to 5:30 PM