Screening Test for `Associates Returning to Work version3.

0 Date: ____________

Name: Last, First, Middle Emp No.: 􀂉 Associate 􀂉 Visitor

Date of Birth: Age: Gender: Select Civil Status: Select

Job Title: Area & Branch Assignment (Office): Isolation/Quarantine Location:
Select
Address: Number & Street Name, Brgy, City/Municipality, Province

Contact Number(s):
Mobile : _____________________ Email add : ________________________
Home : _____________________ FB/Viber : ________________________

Pre-Existing Illnesses or Medical Conditions:

􀂉 Asthma 􀂉 Heart Disease 􀂉 Pulmonary Disease
􀂉 Diabetes 􀂉 Hypertension 􀂉 Sleep Apnea
􀂉 Others, pls specify ________________________________________________________
Are you experiencing the following CoVID-19 like symptoms?
Most Common Symptoms: Less Common Symptoms:

􀂉 Fever, if checked, Temp ___________ 􀂉 Muscle aches and pains

􀂉 Cough, if checked 􀂉 Dry Cough or 􀂉 with Phlegm 􀂉 Sore throat
􀂉 Tiredness 􀂉 Diarrhea
􀂉 Nasal Congestion
Serious Symptoms: 􀂉 Headache
􀂉 Difficulty in Breathing (normal is12 to 20 breaths/minute 􀂉 Loss of taste or smell
􀂉 Chest pain or pressure 􀂉 Nausea or Vomiting
􀂉 Loss of speech or movement

2. Have you worked with or stayed in close proximity with a confirmed CoVID-19 person/patient? 􀂉 YES
􀂉 NO
3. Have you had any contact w/ a person, either a family member, friends or colleagues, with fever, 􀂉 YES
cough, colds, sore throat or any CoVID-19 like symptoms in the past 14-days? 􀂉 NO
4. Have any of your family member, friends or colleagues you are in close contact undergone 􀂉 YES If yes,
a CoVID-19 Test in the past 14-days? 􀂉 NO 􀂉 RT-PCR 􀂉 RTAK
5. Have you visited a hospital with known CoVID-19 case in the last 14 days? 􀂉 YES
􀂉 NO
6. Have you travelled to any location (Province, HUCs, ICCs, Barangays) with CoVID-19 confirmed 􀂉 YES
cases in the past 14-days? 􀂉 NO
7. Have you travelled to any other municipality/city apart from your hometown (home city) in the 􀂉 YES
past 14-days? 􀂉 NO
List the places you have visited today
(for contact tracing purposes)

By signing this document, I hereby authorize PPG to collect and analyze the data I provided for the effective control and prevention
of the spread of COVID-19 virus. I understand that my personal information is protected by RA 10173 (Data Privacy Act of 2012) and
I am fully aware that I am required to provide truthful information as required by RA 11469 (Bayanihan as One Act).

I certify, to the best of my knowledge, that I am in good health and am practicing responsible personal hygiene and physical
distancing. Further, I certify that I am voluntarily entering the work premises out of my own free will; that by leaving my home, I have
increased the risk of contracting the COVID-19 virus and I will NOT hold PPG liable in the event that if I get infected as I cannot
conclusively verify that I have been infected in the workplace or elsewhere.

Printed Name: Signature:

Screened by
Printed Name: Signature:

Recommendation: 􀂉 Return to Work 􀂉 for Medical Consultation

Details: