Mandatory Screening Questionnaire

In line with Globe Telecom's Workplace and Travel Guidelines brought about by the recent Coronavirus Dise
formerly known as Novel Coronavirus (2019-n-CoV), the company would appreciate if you could answer can
questions. Once completed, kindly forward to your Globe Contact at least two (2) days prior to your intended
endorsement and approval.

Employee Name
Company Name
Residence / Address
Office Location (Floor/Tower)

Do you have fever?

Yes No
Are you coughing or having difficulty to breathe?
Yes No
Are any of your close relatives or friends have fever, cough, or having difficulty to breathe?
Yes No
Have you visited other countries in the last fourteen (14) days?
Yes No
If yes, please enumarate below the countries you have visited:
Countries Visited

Do you have family members, close relatives, or friends who recently came back from another country with whom you h
with for the last 14 days?
Yes No
If yes, please enumarate below the countries that they have visited:
Countries Visited

Thank you.
eening Questionnaire

es brought about by the recent Coronavirus Disease (COVID-19),

mpany would appreciate if you could answer candidly the following
ntact at least two (2) days prior to your intended visit for

ng difficulty to breathe?

Date of Entry Date of Exit

ly came back from another country with whom you have been in contact

Date of Entry Date of Exit