GUEST HEALTH DECLARATION FORM

To be completed by all visitors / guest intending to enter Company Premises.

VISITOR'S NAME : Mark Sarmiento DATE: 17 AUG 2020
COMPANY NAME : JATEC PHILS., CORP.
PERSON TO VISIT: Ms. TIN NATANAUAN
PURPOSE OF VISIT: INSTALLATION OF Z AXIS KNOB

For the past 7 days, have you suffered from any of the following conditions?
Please check box of your corresponding answer.
YES NO If yes, since When?: YES NO If yes, since When?:
FEVER: _________________ BODY WEAKNESS: _________________
X
COUGH & COLDS: X _ ________________ DIARRHEA: _________________
SHORTNESS OF
SORE THROAT: X _________________ BREATH: _________________
X
RECENT TRAVEL HISTORY
YES H
NO
T if Yes: When?__________
Arrival to PH?
CHINA H __________
Arrival to PH?
if Yes: When?__________
HONGKONG __________
Arrival to PH?
if Yes: When?__________
TAIWAN __________
Arrival to PH?
if Yes: When?__________
MACAU __________
Arrival to PH?
if Yes: When?__________ Specify Country: ____N/A________________
OTHER COUNTRY __________

This is to certify that information provided above are true and correct.

___Mark Sarmiento ____________ __17 / AUG_/_2020__

VISITOR'S SIGNATURE OVER PRINTED NAME DATE

TO BE FILLED-OUT BY GUARD ON-DUTY

VISITOR'S BODY TEMPERATURE: _________°C ____________________________

SIGNATURE OVER PRINTED NAME OF
***Note: 37.4°C & below (Normal/ may enter company premises) GUARD ON DUTY
37.5°C & above (With Fever/ cannot enter company premises)

REMARKS

ALLOWED TO ENTER COMPANY PREMISES

   
  NOT ALLOWED TO ENTER