HEALTH QUESTIONNAIRE ON COVID-19

Email address *
Your email

Full Name *

Your answer

Age *

Your answer

Sex: *
Male
Female

Position: *

Your answer

Current Address: *

Your answer

Company Name: *

Your answer

For the past 24hrs, did you experience one or more of the following
symptoms? *
Cough
Cold
Fever
Sore Throat
Difficulty in breathing
Body Pain
Headache
Diarrhea
Other:

Did you visit or meet someone after the office hours? *

Yes
No
Other:
If YES, please specify the location:

Your answer

Did you stay in the same close environment of a confirmed COVID 19 case? *
Yes
No
Other:

Have you had any contact with anyone with fever, cough, colds, sore throat for
the past 24hrs? *
Yes
No
Other:

I hereby authorize NCIII to collect and process the data indicated herein for the
purpose of effecting control of the COVID-19 infection. I understand that my
personal information is protected by RA 10173, Data Privacy Act of 2012, and
that I am required by RA 11469, Bayanihan to Heal as One Act, to provide
truthful information.