HEALTH CHECKLIST HEALTH CHECKLIST

(To be accomplished before building entry) (To be accomplished before building entry)

Temperature: Time Taken: Temperature: Time Taken:

NAME: __Helen S. Araneta___________________________ Sex: __F___ Age: __41___ NAME: __Girlie S. Macansantos______________________ Sex: __F___ Age: ___31__
RESIDENCE: _Tugbungan, Z.C._________________________________________________ RESIDENCE: __Boalan, Z.C.____________________________________________________
SECTOR: ____________________________________________________________ SECTOR: ____________________________________________________________
OFFICE: ____COA/DOH-ROIX__________________________________________________ OFFICE: __DOH-ROIX________________________________________________________
CP Number: Office: 9558313________________________ CP Number: Office: __9558313______________________
Personal: ___09977027810__________________ Personal: __0935495609_____________

PARTICULARS YES NO PARTICULARS YES NO

1. Are you experiencing any of the following: / 1. Are you experiencing any of the following: /
a. Sore throat a. Sore throat
b. Body pains b. Body pains
c. Headache c. Headache
d. Fever for the past few days d. Fever for the past few days
If YES, please indicate last temperature If YES, please indicate last temperature
taken. taken.
2. Have you worked together or stayed in the same close / 2. Have you worked together or stayed in the same close /
environment of a confirmed COVID-19 case? environment of a confirmed COVID-19 case?

3. Have you had any contact with anyone with fever, / 3. Have you had any contact with anyone with fever, /
cough, colds, and sore throat in the past 2 weeks? cough, colds, and sore throat in the past 2 weeks?

4. Have you travelled outside of the Philippines in the last / 4. Have you travelled outside of the Philippines in the last /
14 days? 14 days?

5. Have you travelled to any area in NCR aside from your / 5. Have you travelled to any area in NCR aside from your /
home? home?

I hereby authorize THE COMMISSION ON AUDIT, to collect and process the data I hereby authorize THE COMMISSION ON AUDIT, to collect and process the data
indicated herein for the purpose of effecting control of the COVID-19 infection. I understand 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 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. am required by RA 11469, Bayanihan to Heal as One Act, to provide truthful information.

______________ ______________
(SIGNATURE over Printed Name) Date 8-19-2020 (SIGNATURE over Printed Name) Date 8-19-2020