COVID-19 ASSESSMENT FORM

Name of Employee Harrold R. Maravilla Date of Birth March 8,1994

Employee Number 201837 Complete Address:

Department Mechanical
#97 F. Santiago St. Dagp Palad,Pasay City
Contact Number 0956-840-8718

Dear Sir/Ma'am,

MHECO, Inc. is conducting a screening to all our employees to help us prevent the spread of COVID-19 virus & reduce the risk of
exposure to all our staff. Your cooperation is important to assist us determine your readiness to resume work, take precautionary
measures to protect you & everyone within MHECO, Inc. facility. Please answer the following questions honestly and accurately.
MHECO, Inc. treats this form as CONFIDENTIAL & for company's record only. Thank you for your time.

1. In the last 14 days, have you had any travel to/from & transit through restricted countries?

NO YES

If YES, plesase indicate the affected country/ies: ____________________________________

2. Have you had contact with any person who travelled to/from & transited through Restricted Countries in the last 14 days?

NO YES

3. Have you had contact with known COVID-19 patients or persons who have been in contact with known COVID-19 patients
in the last 14 days?

NO YES

4. Please check if you have these symptoms:

fever of 37.8 C or higher shortness of breath

fatigue or weakness headache
sore throat muscle pain or weakness
cough diarrhea
colds

HARROLD r. MARAVILLA 05/20/2020

Employee's Signature over Printed Name Date Signed

OK to resume work
Not OK to resume work
Assessed & Evaluated by:

APRIL P. CARINGAL, RN
Occupational Health Nurse Date Signed

Reviewed By:

MARLON U. RONQUILLO
Safety Head Date Signed