Employee Name: ___________________________________ Date Filed: _________________________

Project / Department: ___________________________________ Location: _________________________

Project / Department Supervisor: ______________________________________________________________________

COVID-19 Incident Report Form

Personal Information:

Current Residential Address: __________________________________________________________________________

__________________________________________________________________________________________________
Active Numbers: (mobile) ______________________________ (whatsapp) ___________________________________
Date of Birth: ________________________________________ Age: _________________________________________

Kindly check the appropriate box if you are experiencing the following :

Fever Yes, Date Started ____________ Duration of Fever __________ days No

Cough Yes, Date started ____________ No
Sore throat Yes, Date started ____________ No
Runny Nose Yes, Date started ____________ No
Head ache Yes, Date started ____________ No
Join Pain Yes, Date started ____________ No
Chest Pain Yes, Date started ____________ No
Diarrhea Yes, Date started ____________ No
Lost of Taste or smell Yes, Date started ____________ No
Difficulty breathing Yes, Date started ____________ No
Nausea or vomiting Yes, Date started ____________ No

Recent History

1. Have you been in close contact (within 6 feet for at least 10 minutes) Yes, when ____________ No

with anyone while they had COVID-19?

2. have you been in close contact (within 6 feet for at least 10 minutes) Yes, when ____________ No
with anyone while they had COVID-19 symptoms?
3. Are you living with anyone who is sick, quarantined, or isolating? Yes No
4. Have you traveled outside metro manila or outside the project site Yes No
within the last 14 days?

COVID-19 Testing Details:

Initial COVID-19 Testing: Please select by shading the O

O Rapid Test (with IgG and IgM) Date of Rapid Test: _______________________________________
O Antigen Test Date of Antigen Test: _______________________________________
Conducted / Administered by : _________________________________________________________________________

Confirmatory COVID-19 Swab Testing: Please select by shading the O

O Saliva Test Date of Saliva Test: _______________________________________
O RT-PCR Test Date of RT-PCR Test: _______________________________________
Conducted / Administered by : _________________________________________________________________________

Estimated Date of COVID-19 Possible Exposure: ___________________________________________________________

P a g e 1|2
Details of Incident or Exposure:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Has employee been seen by primary physician or at a clinic or hospital? Yes ________No_______

If YES, give Date of visit / check-up ________________________________________

What were the physicians’ recommendations to employee?
_____ Self-monitor and continue to report to work
_____ Self-isolation or self-quarantine at home
_____ Hospitalizations, if needed.
_____ Other/s, pls. specify: ___________________________________________________________________________

If NO, he/she decided to:

_____ Self-monitor and continue to report to work
_____ Self-isolation or self-quarantine at home
_____ Surrender his/herself to LGU
_____ Hospitalizations, if needed.
_____ Other/s, pls. specify: ___________________________________________________________________________

I hereby declare that the information Prepared by: Received & Confirmed by:
given in this application is true and correct
to the best of my knowledge and belief.

COVID-19 Positive Employee Safety Officer / Authorized Personnel Admin & HR / Authorized Personnel
(Name, Signature and Date Accomplished) (Name, Signature and Date Accomplished) (Name, Signature and Date Accomplished)

/conversion/tmp/activity_task_scratch/543252711.docx

P a g e 2|2