HEALTH CHECKLIST

NOTE: All Officials. Employees and visitors are required to accomplish this form prior to entry to company premises for monitoring
purposes

Temperature:

Name: Sex: Age:

Residence:
Nature of Visit:
Please check one
Official: 
If official, fill-in company details below
Personal: 
Company Name:
Company
Address:

Yes No
1. Are you experiencing: a) Sore throat (pananakitnglalamunan /
(nakakaranaskabang: masakitlumunok)  
) b) Body pains (pananakitngkatawan)
 
c) Headache (pananakitngulo)
 
d) Fever for the past few days
(Lagnatsanakalipasnamgaaraw)  
2. Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case? (May nakasamakaba o  
nakatrabahongtaonakumpirmadong may COVID-19 / may impeksyonng
coronavirus?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat
in the past 2 weeks? (Mayroonkabangnakasamana may lagnat, ubo, sipon o 
sakitnglalamunansanakalipasngdalawang (2) lingo?)

4.Have you travelled outside of the Philippines in the last 14 days? (Ikawba ay
nagbyahesalabasngPilipinassanakalipasna 14 naaraw?)  

5. Have you travelled to any area in NCR aside from your home?  
(IkawbaaynagpuntasaibapangpartengNCRoMetroManilabukodsaiyongbahay?)
Specify(Sabihin kungsaan):

Iherebyauthorize[nameofestablishment],tocollectandprocessthedataindicatedhereinforthe
purposeofeffectingcontroloftheCOVID-19infection.Iunderstandthatmypersonalinformation 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 truthfulinformation.

Signature: Date:
 HEALTH CHECKLIST

NOTE: All Officials. Employees and visitors are required to accomplish this form prior to entry to company premises for monitoring
purposes

Temperature:

Name: Sex: Age:

Residence:
Nature of Visit:
Please check one
Official: 
If official, fill-in company details below
Personal: 
Company Name:
Company
Address:

Yes No
1. Are you experiencing: e) Sore throat (pananakitnglalamunan /
(nakakaranaskabang: masakitlumunok)  
) f) Body pains (pananakitngkatawan)
 
g) Headache (pananakitngulo)
 
h) Fever for the past few days
(Lagnatsanakalipasnamgaaraw)  
2. Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case? (May nakasamakaba o  
nakatrabahongtaonakumpirmadong may COVID-19 / may impeksyonng
coronavirus?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat
in the past 2 weeks? (Mayroonkabangnakasamana may lagnat, ubo, sipon o 
sakitnglalamunansanakalipasngdalawang (2) lingo?)

4. Have you travelled outside of the Philippines in the last 14 days? (Ikawba
ay nagbyahesalabasngPilipinassanakalipasna 14 naaraw?)  

5. Have you travelled to any area in NCR aside from your home?  
(IkawbaaynagpuntasaibapangpartengNCRoMetroManilabukodsaiyongbahay?)
Specify(Sabihin kungsaan):

Iherebyauthorize[nameofestablishment],tocollectandprocessthedataindicatedhereinforthe
purposeofeffectingcontroloftheCOVID-19infection.Iunderstandthatmypersonalinformation 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 truthfulinformation.

Signature: Date:
 HEALTH CHECKLIST

NOTE: All Officials. Employees and visitors are required to accomplish this form prior to entry to company premises for monitoring
purposes

Temperature:

Name: Sex: Age:

Residence:
Nature of Visit:
Please check one
Official: 
If official, fill-in company details below
Personal: 
Company Name:
Company
Address:

Yes No
1. Are you experiencing: i) Sore throat (pananakitnglalamunan /
(nakakaranaskabang: masakitlumunok)  
) j) Body pains (pananakitngkatawan)
 
k) Headache (pananakitngulo)
 
l) Fever for the past few days
(Lagnatsanakalipasnamgaaraw)  
2. Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case? (May nakasamakaba o  
nakatrabahongtaonakumpirmadong may COVID-19 / may impeksyonng
coronavirus?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat
in the past 2 weeks? (Mayroonkabangnakasamana may lagnat, ubo, sipon o 
sakitnglalamunansanakalipasngdalawang (2) lingo?)

4. Have you travelled outside of the Philippines in the last 14 days? (Ikawba
ay nagbyahesalabasngPilipinassanakalipasna 14 naaraw?)  

5. Have you travelled to any area in NCR aside from your home?  
(IkawbaaynagpuntasaibapangpartengNCRoMetroManilabukodsaiyongbahay?)
Specify(Sabihin kungsaan):

Iherebyauthorize[nameofestablishment],tocollectandprocessthedataindicatedhereinforthe
purposeofeffectingcontroloftheCOVID-19infection.Iunderstandthatmypersonalinformation 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 truthfulinformation.

Signature: Date:
 HEALTH CHECKLIST

NOTE: All Officials. Employees and visitors are required to accomplish this form prior to entry to company premises for monitoring
purposes

Temperature:

Name: Sex: Age:

Residence:
Nature of Visit:
Please check one
Official: 
If official, fill-in company details below
Personal: 
Company Name:
Company
Address:

Yes No
1. Are you experiencing: m) Sore throat (pananakitnglalamunan /
(nakakaranaskabang: masakitlumunok)  
) n) Body pains (pananakitngkatawan)
 
o) Headache (pananakitngulo)
 
p) Fever for the past few days
(Lagnatsanakalipasnamgaaraw)  
2. Have you worked together or stayed in the same close environment of a
confirmed COVID-19 case? (May nakasamakaba o  
nakatrabahongtaonakumpirmadong may COVID-19 / may impeksyonng
coronavirus?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat
in the past 2 weeks? (Mayroonkabangnakasamana may lagnat, ubo, sipon o 
sakitnglalamunansanakalipasngdalawang (2) lingo?)

4. Have you travelled outside of the Philippines in the last 14 days? (Ikawba
ay nagbyahesalabasngPilipinassanakalipasna 14 naaraw?)  

5. Have you travelled to any area in NCR aside from your home?  
(IkawbaaynagpuntasaibapangpartengNCRoMetroManilabukodsaiyongbahay?)
Specify(Sabihin kungsaan):

Iherebyauthorize[nameofestablishment],tocollectandprocessthedataindicatedhereinforthe
purposeofeffectingcontroloftheCOVID-19infection.Iunderstandthatmypersonalinformation 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 truthfulinformation.

Signature: Date: