Health Declaration Form (COVID-19)

The safety of employees and vendors is the top priority of MDC and its Subsidiaries. As the outbreak of COVID-19
continues, the management continues to be vigilant in preventing its spread and reduce the potential risk of
exposure of everyone in the workplace. Please answer this form to help us take the necessary precautionary
measures to protect you and everyone in the property premises.

Visitors Full
Name Last Name First Name Middle Name

Contact Number: Sex: Age: Temperature:

Date of Visit: Company to Visit: Purpose of Visit: Person to Visit:

1. Are you experiencing: a. Fever Yes No

b. Cough Yes No
c. Colds Yes No
d. Headache Yes No
e. Throat Ache Yes No
f. Body Ache Yes No
g. Diarrhea Yes No
h. Loss of Taste Yes No
2. Do you have any of the following pre-existing illness: hypertension, diabetes Yes No
mellitus, pulmonary disease, kidney disease, dialysis, pregnancy, cancer, undergoing
chemotherapy

3. On exposure, have you provided direct a. with PPE Yes No

care to Suspect, Probable or Confirmed
COVID-19 individual/s? b. without PPE Yes No

4. Have you had face-to-face contact with Probable or Confirmed COVID-19 Yes No
individual/s within 1 meter and for more than 15 minutes?

5. Have you had direct physical contact with Probable or Confirmed COVID-19 Yes No
individual/s?

6. Have you travelled from a location where there is sustained community level Yes No
transmission?

Certification and Data Privacy Content

I certify that the information I have provided is true, correct and complete. I hereby give my full consent to Makati
Development Corporation (MDC) and its Subsidiaries to collect, record and process information, whether personal, sensitive,
or privileged, pertaining to myself for the purpose of drafting and implementing internal policies related to the prevention
and/or containment of COVID-19 in the workplace. In this connection, I acknowledge that I have read, understood, and/or
have been duly informed of the terms and conditions pertaining to the data privacy practices of MDC and its Subsidiaries.
I hereby express my full conformity thereto.

___________________________________________ ________________________________________
Name and Signature Date