SMI COVID-19 Health Survey Form - Revised

The purpose of this form is to gather information pertaining to the health status of all visitors visiting
the SMI premises or having engagement with SMI employees/contractors.

1. Name: TEDDYLUZ R. ALIGATA

2. Visitors:
 Government
 Private Sector

 Others

3. Department/Region: 12
4. What is your COVID-19 Status:
 Not a COVID-19 Case
 Suspect
 Probable
 Confirmed
5. Please select the signs and symptoms that you are experiencing right now.
 Sore throat
 Body pains / Fatigue
 Headache
 Fever (>37.5°C)
 Coughs and colds
 Diarrhea
 Runny Nose
 Nausea
 None of the above
6. Have you worked together or stayed in the same close environment with a confirmed
COVID-19 case in the past 14 days?
 YES

 NO

7. Have you had any contact with anyone with sore throat, body pain, headache, fatigue, fever,
coughs, colds, diarrhea, runny nose and/or nausea in the past 14 days? Contact means direct
physical contact, or in proximity of less than 1.0 meter distance for at least 15 minutes.
 YES

 NO

8. Have you travelled outside of the Philippines in the last 14 days?

 YES
 NO

If YES, where did you travel? ______________________________________

9. Have you travelled to areas that are under enhanced community quarantine (ECQ) or
Modified ECQ? Or have come from NCR / Cebu City / Davao City in the past 14 days and now
returning to workplace?
 YES
  NO

If YES, where did you travel? ______________________________________

10. Have you travelled outside your approved work location since the last health survey?
Considered as outside areas are those where you do not conduct official business, such as
malls, supermarkets / stores, restaurants, drugstores, beach / mountain resorts, and others.
 YES
 NO

If YES, where did you travel? ______________________________________

11. Have you been vaccinated for Covid-19?

 YES
 NO

If YES, what vaccine did you have? JOHNSON AND JOHNSON JANSEN

When was you first dose? ___________________________

When was your second dose? ________________________

 I confirm that the information submitted is correct.

TEDDYLUZ R. ALIGATA
Name and Signature

AUGUST 17, 2021

Date