COVID-19 HEALTH SCREENING FORM

Employee Guest Others

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Name: _________________________ Age/Sex: _____ Contact No.: ____________________

Address: ___________________________________________________________________

In the past 2 weeks did you have any of the following: YES NO

1. Respiratory Symptoms
A. Cough
B. Shortness of breath and/or difficulty of breathing
C. Colds
D. Throat pain
E. Other respiratory symptoms
F. Influenza like symptoms (headache, muscle and joint
pains, diarrhea, loss of smell or taste); runny nose
2. Fever of 37.5°C
3. History of COVID-19 infection
4. Household member diagnosed with COVID-19?
5. Residence in an area placed under HARD LOCKDOWN (if YES, write
name of BARANGAY, CITY and DATE OF LOCKDOWN on the space)
6. Means of Transportation to Workplace: (Check accordingly)
__Public Transportation __Shuttle Bus _ Private Vehicle (# of passenger if
Carpool ___)

I hereby I hereby authorize the Management of ______________________________, to

collect and process the data indicated herein for the purpose of effecting control of the CoVID-
19 infection. I understand that my personal information is protected by R.A. No. 1017, otherwise
known as the Data Privacy Act of 2012, and that I am required by R.A. No. 11469, otherwise
known as the Bayanihan to Heal as One Act, to provide truthful information.

Signature over complete printed name: ______________________________

Date: __________

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To be filled-out by the Security Personnel:

Recorded Body Temperature: __________

Name of Security Personnel: ______________________________ Time: _______________