QUARANTINE CLEARANCE FOR EMPLOYEES

(To be filled out individually)

Name of Employee and Cats No. _______________ Date of Submission________________

Position: __________________________________ Department _____________________

Classification (Please check):

A. F1 : _______________________ C. F1 turned Positive: _________________

B. Positive: ____________________ D. F2: ______________________________
E. F2 turned F1:________________

Details for ABC&E:

Person whom the employee got exposed to: ________________
Home Quarantine Dates: ________________
Date of Swab Test: _________________
Dates of Quarantine at Isolation Facilities or Hospitals _________________
Dates of Extended Home Quarantine (if required) _________________
Note: For Regular and Casual Employees, please fill out Permission/Grant of Authority of
Absence from Work Form to be effected in the Leave Forms; and submission of Medical Clearance
is
still a must

__________________________________ __________________________________
Signature of Employee Name and Signature of Department Head

_________________________________________
Name and Signature of EOC Authorized Signatory

Details for D&E:

Person whom the employee got exposed to (F1): __________________
Work from Home Dates: __________________
Note: Attach Accomplishment Report

__________________________________ __________________________________
Signature of Employee Name and Signature of Department Head

_________________________________________
Name and Signature of EOC Authorized Signatory
(to authenticate timeline)

Governor’s Office, 4th Floor, Executive Building, Provincial Capitol Complex, Cabidianan, Nabunturan, Davao de Oro
 DdO-Form-043

Governor’s Office, 4th Floor, Executive Building, Provincial Capitol Complex, Cabidianan, Nabunturan, Davao de Oro