AboitizLand HEALTH DECLARATION FORM Date & Time (Petsa at Oras): S-2. ="20 |: 22 m Temperature (Temperatra} Name (Pangalon} Wino BRYAN V.ENno10 Sex (Kasarian) (Ededy 7 Project Name (Pangolan ng Proyekfo} SEAFRONT WEST Den ces. : eee Company (Kumparyang Pinagtrarabahuhon): ENEQ GREEN Job Designation (Trabaho):_GAFETY OFFICER Contact Number (Matalawagang Numero) Home Address (Address ng Tahanan): Lipa. City, Be ances Purpose of Visit to Site (Dahilan ng Pagpasok sa Sie) ‘Type of Vehicle Used (Ung Gam na Sasakyan) Selec fom the flowing (Pumii sa sumusunod) Select rm the folowing (Pun a sumusured) 2° WorkerStaff (Dio nagtatrabaho) Public Transportation (Pampublkong sasahyan Delivery (May -dedeliverinahaid) Personal Vehicle (Saniing ssalyan) Official Work Order (Opisya na gawain) | Company Vette (Sence ng kumpanya) Housing Inquiry (Magttanong tungkol sa bahay) | No vehidl used (Hind gua ng sasahyan Others bapa) Others bapa) = T. Are you experiencing a Te oo | | a Sore throat (pananak ng llamunan / masa umunok) o | 7 'b Dry Cough or with phlegm (abong tayo 0 ubong may plea) a_| «. Colds (sipon) g_| [Body pains (pananalt ng Kelawan] — z . Headache ipananakirg wo) _ To az Fever orth pst ew day Lana sa ralaipasnamgeweu) | | at ¢.Dficuy of breathing (ap sa paghinga) a o | Zo you have ps exsing heal condions suchas Wayroon Fa bang tacahiayang Fondmyong | | et” Pangkalusugantued ng): Hypertension, Diabetes, Asthma, Tuberculosis, Cancer, Pregnant (bunts? iL ‘E Have you worked together or stayed in the same cose endronrentofaconfimed COV | wr case? May nakasama ka bao nakarabahong fo a kumpimadong may COVID-19/may | impeksyon ng coronavirus?) _ - 7 Have you had any contact with anyone wt fever, cough, cols and sre throat in the past two a e ‘weeks? (Mayroon ka bang nakasama na may lagna, ubo, spon osaktngllamunan sa nakalpas na dolawang (2) go?) _ . Have you traveled ouside ofthe Philppnes nthe last 14 days? (haw ba ay nagbyahesalabas | O | ct 1g Piipnas sanakalias na 14a raw?) _ _ 3. Have you aveled to any area NCR aside rom your home? (aw ba a nagpuna sabe pang |) a parte NCR o Metro Manila bukod a iyong bahay?) | Speci (Sabiin kung seen) : £ | Abotaand Inc. adits subsidiaries to collect and process the data indicated herein forthe purpose of fecting aa Ovi 18 ict, Lundertnd thal my ersorl onto pte by RA 10173, Daa Pray Act 2012 ‘and that am required by RA 11469, Bayaninan to Heal as One Act. to provide thf infomation AbodizLand, Ic. al ang mga subsidiary nio na kletahin at proseso ang impormasyon na nakasaad do Jang COVID-19 infection, Nauunawaan kona ang aking personal naimpormasyon ay potktado ng RA 2012 at kiekalangang magbigay ng makalotohanang impormasyon ayon sa RA 11469 Bayentan to= Republic of the Philippines CITY OF LIPA OFFICE OF THE CITY MAYOR CERTIFICATION This is to certify that _\\AQ enon WL. Ecco 24 yle_ isfare resident/s of Lipa City, This CERTIFICATION is issued to allow hisher/them to travel to a using a vehicle with Ls on 0 Non O-2\ Anan. Any assistance given to them will be greatly appreciated Issued this_\C\ day of May 2020 at Lipa City, Batangas. Scanned with CamScannerConrado F. Segismundo, M.D., M.O.H. 7 Industrial - Occupational Medicine / Family Medicine egismundo Medical Cli Mon - 8:00 0 $e M Reco Avene sunday 8100 am to 12 00m Lipa City, Batangas. 4217 (043) 7156.02.56 Medical Certificate ee 2 —— This is to ceniy that Ay/do bryan Eclra, consulted with the undersigned last yvo.. 723. dow because of SELIM Ohecle x ee [eto 7 ayry brag RE revved Clinical Impression Ee Bates nbvime y | He / She is advised to rest for days. | He / She is fit to work starting 27, Dom MA Cenk boty 722 p- by} clone This Medical Certifidate is issued per paticnt’s request but is not valid for medico legal purposes. Scanned with CamScanner