DAILY COVID-19 SURVEILLANCE FILL-UP/CHECKLIST FO

PANGALAN: ___________________________________
EDAD: _______
LUGAR NG TIRAHAN: ___________________________________________
LUGAR NG TRABAHO:
PANGALAN NG PROYEKTO:

MAY
PRESENSYA NG MGA SUMUSUNOD
(Presence of the following) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Temperatura (NORMAL UP TO 37.5°)

RESPIRATORY INFECTION
Ubo (Cough) (productive or non-productive cough)
Igsi ng paghinga (Shortness of breath)
Sipon (colds)
Namamagang lalamunan (sore throat)
Tumutulong Sipon (Runny nose)
Naninikip na ilong (nasal congestion)
Nananakit na kalamnan (muscle pains)
Sakit ng ulo (Headache)
Hirap sa paghinga (Difficulty of Breathing)
Pagtatae (Diarrhea)
Pagkawala ng pang-amoy (Loss of Sense of Smell)
Pagkawala ng panlasa (Loss of Sense of taste)
WALA (NONE)

Kung mayroong presensya ng mga nasa taas, simula kailan?

(If identified with presence of the above, since when?)

PIRMA:

Pagpapahayag: Ang mga impormasyon na aking ibinigay dito ay totoo, tama at kumpleto. Aking na-iintindihan na ang hindi pags
seryosong kinahihinatnan. (Article 171, & 172 of the Revised Penal Code of the Philippines and Republic Act No. 11332.)
CE FILL-UP/CHECKLIST FORM

Kasarian: _________
Telepono: _______________
Trabaho: __________________
Kontraktor:

MAYO
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

na-iintindihan na ang hindi pagsagot sa mga katanungan o ang maling sagot ay maaaring may
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 PANGALAN: ___________________________________
EDAD: _______
LUGAR NG TIRAHAN: ___________________________________________
LUGAR NG TRABAHO: STA. ISABEL, CALAPAN CITY, ORIENTAL MINDORO
PANGALAN NG PROYEKTO: _____________________________________________________________________

PRESENSYA NG MGA SUMUSUNOD

1 2 3 4 5 6 7 8
(Presence of the Following)
Temperatura (Temperature)

RESPIRATORY INFECTION
Ubo (Cough) (productive or non-productive cough)
Igsi ng paghinga (Shortness of breath)
Sipon (colds)
Namamagang lalamunan (sore throat)
Tumutulong Sipon (Runny nose)
Naninikip na ilong (nasal congestion)
Nananakit na kalamnan (muscle pains)
Sakit ng ulo (Headache)
Hirap sa paghinga (Difficulty of Breathing)
Pagtatae (Diarrhea)
Pagkawala ng pang-amoy (Loss of Sense of Smell)
Pagkawala ng panlasa (Loss of Sense of taste)
WALA (NONE)

Kung mayroong presen

(If identified with presence of the above, since when?)

PIRMA:

Pagpapahayag: Ang mga impormasyon na aking ibinigay dito ay totoo, tama at kumpleto. Aking na-iintindihan na an
seryosong kinahihinatnan. (Article 171, & 172 of the Revised Penal Code of the Philippines and Republic Act No. 1133
 DAILY COVID-19 SURVEILLANCE FILL-UP/CHECKLIST FORM

Kasarian: _________
Telepono: _______________
Trabaho: __________________
Kontraktor:
_______________

MAYO
9 10 11 12 13 14 15 16 17 18

Aking na-iintindihan na ang hindi pagsagot sa mga katanungan o ang maling sagot ay maaaring may
and Republic Act No. 11332.)
ST FORM

__________
SANLAHI GROUP OF BUILDERS INC.

19 20 21 22 23 24 25 26 27 28
29 30 31