Daily Health Screening Checklist Form No.

2 (Version May 25, 2020)

Daily Health Screening Checklist - COVID19 Temperature:

(For Visitors)

Name: ____________________________________ Sex: ___________ Age: ___________

Residence (Complete Address): ______________________________________________
Contact No. (Tel./Mobile No.):________________________________________________
Name/s of SGV staff to be visited: ____________________________________________
Location/Area (Floor/Room/Building): ____________________ Time: ______________
Nature of Visit: Official Personal (If Official, fill-in company details below)
Company Name: ____________________________________________________________
Company Address: __________________________________________________________

Due to COVID19 outbreak, SyCip Gorres Velayo & Co. (SGV) is taking precautionary
measures to prevent further spreading of COVID19. We are asking for your
cooperation in answering the questions below.
Instruction: Kindly tick the box and provide information as needed.

Question Yes No

1. Have you or someone living in your home been ☐ ☐

diagnosed with, or is suspected of having, COVID19
within the past 21 days?
2. Do you have any of the following: ☐ ☐
• Fever
• Dry cough
• Shortness of breath
• Headache
• Nasal congestion/Runny nose
• Sore throat
• Chills/Repeated shaking with chills;
• Diarrhea
• Fatigue and weakness
• Muscle aches and pain
• New loss of smell or taste

3. Have you had close contact or worked together or ☐ ☐

stayed in the same close environment with a person
suspected or confirmed with COVID-19 infection
within the past 21 days?
Daily Health Screening Checklist for COVID 19 in compliance with DTI and DOLE Interim Guidelines on Workplace Prevention and Control of COVID-19
 Page 2

4. Have you had any contact with anyone with fever, ☐ ☐

cough, colds, and sore throat in the past 21 days?
5. Have you travelled outside of the Philippines in the ☐ ☐
past 21 days?
6. Have you travelled to any area in NCR or outside ☐ ☐
NCR aside from your home or office? If yes, please
specify: _______________

By answering, signing and submitting this Screening Checklist, I confirm that I understood all the
contents of this Daily Health Screening Checklist and voluntarily waive any claim against SGV and/or
any of its Partners, Principals, Employees, Staff and Personnel and hold them harmless and free from
any claim or liability arising from or relating to possible exposure to COVID-19 due to my entry to any
part of SGV’s premises.

I hereby consent and authorize SGV to collect, process, and store the information and data indicated
herein for the purpose of effecting control of the COVID-19 infection including their lawful disclosure to
the appropriate parties and authorities pursuant to applicable laws and regulations.

I understand that my personal information 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 truthful information. Further,
I hereby agree to observe and follow the health and safety workplace measures, protocols, policies and
procedures of SGV and the building administration for the prevention of the outspread of COVID-19.

___________________________ _________________________
Signature over printed name Date

We highly appreciate your response. Thank you!

Privacy Notice

In line with SGV & Co’s compliance with Data Privacy Act of 2012 and its Implementing Rules and Regulations, any information
obtained from you in this checklist will be used solely for evaluation on possible exposure to COVID19. For more details on how
we process your data, you may visit our Privacy Policy at our website, http://www.sgv.ph/data-privacy/.

Daily Health Screening Checklist for COVID 19 in compliance with DTI and DOLE Interim Guidelines on Workplace Prevention and Control of COVID-19