STATEMENT OF MANAGEMENT’S RESPONSIBILITY

FOR MAINTAINING WORKPLACE HEALTH STANDARDS

1. I _________________________ owner/authorized representative of the management
of ______________________________ (the “Company”), with business address at
_________________________________ hereby acknowledges and affirms that it
has complied and shall continue to comply with the Department of Health – Region 7
(“DOH”) Workplace Health Standards and those required by the City of Mandaue as
may be applicable to the business.

2. I/The Company further affirms that it shall be responsible for maintaining the health
and safety of all its employees in accordance with the said DOH Workplace Health
Standards.

3. The management maintains its prerogative over its employees, thus, I/The Company
confirms that I/We MAY subject all our working employees to be deployed for Rapid
Anti-body Diagnostic Testing, only if the need arises, and for Confirmatory RT-PCR
Testing for Covid-19, if found positive, through the company or other available means.

4. The Company acknowledges furthermore the right of the authorized personnel of

the City of ____________ to conduct random inspection/audit of the Company’s
premises and working conditions for the purpose of determining compliance with
the DOH Workplace Health Standards and pertinent documents to support the same.

5. Lastly, the Company agrees that should it be found to be in violation of the DOH
Workplace Standards, it shall be imposed corresponding penalties as stipulated in
existing Executive Order, Ordinance, and National Issuances and its Permit-To-
Operate may be revoked, including the Business Permit, necessitating the closure of
the Company’s operations by the City of Mandaue, after being given adequate due
process to rectify the violations.

IN WITNESS WHEREOF, I have hereunto set my hands this ___________ at the City of
Mandaue, Philippines.

_______________________________
Owner/President (or equivalent)

________________________________________
Designated Company Official (or equivalent)

SUBSCRIBED AND SWORN TO:

___________________
___________________
___________________
___________________