TEMPERATURE: 30-0 Dunne Susurvinate ‘amon EEE roe SSUES LARES and ITP require ts emoyees and vistors to fiat the heath decaravion form below. Please subi this Wa erat feast 24 ours prior to your scheduled appotntment or itended st Yo: pmo nureealte 7.5) and ayciementeqaves co ph {ARES and ITP also reserve the ight to deny entry othe IMC premises based onthe answers provided below ane ‘EMPLOYEE NUMBER: pot: ‘ADpReSS: CONTACT NUMBERS: 414. Dia you travel to any couriey o¢ locally with a documented localized oF community transmission of COVIO-18 Inthe past marin? TD YES" LoctlonyDateof Lest Trvel & Say NO 2. Were you In cose contact (nakahalubio, kasama sa bahay, 0 nap-alage) wih anyone who is a ‘suspected or confimed e480 of COVID-10? 3 1d you experence any one cf the folowing signs and symptoms? gna (Lagat 1 stomacnacne Parana ng yan) 1 covgncusey 1D. a0y seb Parana ng haw) sneezing (Poptahing 1D cnsyrangnig 1D. Runny nos (ay soon aradong fog) 1 Atergernies Tweet natn (ating nora) 1D. verting Papas) shortness osath (rap pophinge) 1 Dimes (eaptoe) ewe ngane ee,sinatn a) Lateran cma oy 9 1D Omer ibe pong stoma 4. Have you been lagnosed with any of he flowing condone? Smee pn ees sanash 3 tormenta 0 wy Dees oe etme ve 2 myome © cumeroamin nese sleet eeeree nef (ol emranmes © atmo a a inmate nae neencenterenemerrrt es eee aerated ae See | Scanned with CamScanner