AXAPMC Shape nt re SUNSHINE PLAZA MALL Health Declaration Form (v.2) COVvID-19 ‘Tie safety of our people remains as the top priority of Sui ‘Mall. AS the ‘outbreak of Coronavirus Disease 2019 (COVID-19) continues, it Is incumbent upon all of us to remain’ 1 vigglant in preventing Its spread and reduce the potential risk of exposure of everyone in their workplace found within the confines of our malls. Please answer this form'to help us take the necessary precautionary measures to protect you and our community: Employee's Full Name: Last Name First Name Middle Name Contact Number: Sex: Age: ‘Temperature Reading: 1. | Did you visit a hospital, clinic or medical health facility in the past 14 days? Ores no Im the last 14 days and at present, did you experience or are you experiencing 2. | any of the following: fever, colds, cough, sore throat, body pains, headache, or | [_] Yes No. difficulty in breathing? = 43, | Inthe last 14 days, have you been in contact with anyone with fever, cough, %e No colds and sore throat? In the last 14 days, have you been in close contact with a person or patient who 4, | hat ether (a) displayed any symptoms associated with COVID-19, regardless of | [~) eg Cone ” | whether the same person has been tested for COVID-19 or not, or (b) has been confirmed positive for COVID-19? 5. | In the last 14 days, have you travelled outside the Philippines? Yes No «¢, | Have you travelled to any area in NCR aside from your home? Specify ved Ps |The Sunshine Paza Malis agents, assigns or thorized repreentative/s reserves the ight to refuse entry into the al prmies sry person who fis or ones accomotah and vue ta for and who it reasonably deems may pose a risk to other peopl.Certification and Data Privacy Consent | certify that the information | have provided is true, correct and complete. | understand that | am required to RA No. 11469 (Bayanihan to Heal as One Act) to provide truthful information, and'that my fallure to answer or any false/wrong information given may be a ground for the filing of appropriate cases against me under the law. | hereby give thy full consent to 5: Plaza Mall (the “Company”) to collect, record, and process information, whether personal, sensitive or privileged, pertaining to myself for the purpose of drafting and implementing policies related to the prevention ‘and/or containment of COVID-19. In this connection, | acknowledge that | have read, understood and/or have been duly Informed of the terms and conditions pertaining to the data privacy practices of the Company as reflected in the Company's Data Privacy Policy at hitins://www.ayalaland.com ph/priyacy-policy/ andi hereby express my full conformity thereto. ‘Name and Signature