Health Surveillance Form

2019 NOVEL CORONA VIRUS

(Version 2)

NAME: JOHN ERVIN V. AGENA______________ DATE:

____________________________
SEX : MALE___________ Age ____31__________ Contact Number: 09756160975
MARITAL STATUS: MARRIED_____________ NAME OF SPOUSE : CHARMAINE M.
AGENA
HOME ADDRESS: SAN PEDRO, BAUAN, BATANGAS
DEPARTMENT OR ORGANIZATION : STP PROJECT (TEEM INC.)
POSITION : SAFETY OFFICER 3

KINDLY PUT A CHECK( ) IF YES OR NO.

A. Clinical Symptoms/Signs YES NO Remarks
Do you currently experience:
1.Fever of 37.8 degrees Celsius or greater?
2. Flu like symptoms such as cough, colds and
headache?
3.Shortness of Breath and Easy Fatigability?
4. Sore throat or Runny nose?
5. Symptoms of diarrhea
B. Risk of Exposure to NCOV
Do you have any:
1.Recent contact with a confirmed or
suspected 2019 NCOV patient?
2. Recent travel to High Risk Countries or
countries with sustained local transmission?
3. Are you staying at home with any medical
service provider treating COVID 19 cases OR
who is working in a health care facility with
COVID19 cases?
4. Exposure to farm or wild animals?
5. Recent visits to health care facility that had
COVID 19 cases?

Vital Signs: BP__________ HR__________

Temp________ RR__________

Physical Examination: ___________________________________________

___________________________________________

Treatment Plan: _______________________________________________

_______________________________________________

Recommendation:________________________________________________
________________________________________________
________________________
_______________________
Examining Physician Nurse on
Duty

INFORMED CONSENT

I, hereby give my consent to be examined by the

Medical Clinic Team of Alaska Milk Corporation SPL
Plant and submit myself to medical inspection protocol
of the company clinic if my temperature is more than
37.8 degrees Celsius and/or experiencing fever in
relation to the Corona Virus Disease 2019 (COVID 19)
or I am monitored due to symptoms of COVID 19.
I understand that Alaska Milk Corporation
reserves its right to ensure its employees of the
optimum utilization of its occupational safety and
health measures to control and prevent the spread of
the disease in the work place.

I understand that Alaska Milk Corporation will

secure and protect my personal and health information
with the utmost confidentiality and will not disclose or
process the same without my prior written consent.

JOHN ERVIN V. AGENA

FULL NAME AND SIGNATURE

______________________
DATE