HEALTH ASSESSMENT FORM

NAME___________________JOHN MARK M. SALAZAR_____________________ TEMPERATURE___________°C_

AGE____27____ GENDER ____M____ CONTACT NOS.__09359793801________EMPLOYEE__/__STUDENT_____

POSITION__LIBRARY ASSISTANT_ COLLEGE/DEPARTMENT____LRC_____ CAMPUS __PAMPANGA__________

Markahan ng (✓) ang sagot sa mga sumusunod na katanungan. YES NO

1.Are you experiencing (nakakaranas ka ba ng):
a) Sore Throat (Pananakit ng lalamunan/masakit lumunok) ✓
b) Body Pain (Pananakit ng katawan) ✓
c) Headache (Pananakit ng ulo) ✓
d) Fever for the past two weeks (Lagnat sa nakalipas na 2 linggo) ✓
2. Have you worked together or stayed in the same close environment with a
` ✓
confirmed COVID-19 case or PUI under self-quarantine in your house or in
your neighborhood?
(May nakasama ka ba o nakatrabahong tao na kumpirmadong may COVID-19/
may impeksyon ng coronavirus o PUI na kasama mo naka quarantine sa bahay o sa kapitbahay?)
3. Have you had any contact with anyone with fever, cough, colds, and sore throat in the past 2 weeks ✓
(Mayroon ka bang nakasama na may lagnat, ubo, sipon o sakit ng lalamunan sa nakalipas na
dalawang (2) linggo?
4. Have you travelled outside of the Philippines in the last 14 days? (Ikaw ba ay nagbiyahe sa labas ✓

ng Pilipinas sa nakalipas na 14 na araw?)

4. Are you currently having the following conditions:
(Sa kasalukuyan, ikaw ba ay mayroon ng mga sumusunod na kundisyon)
/ 60 years old and above (May edad na 60 taong gulang o pataas) ✓
/ Ongoing pregnancy (Nagbubuntis) ✓
/ Hypertension (Mataas ang presyon ng dugo) ✓
/ Heart disease (Sakit sa puso) ✓
/ Diabetes Mellitus (Diabetes) ✓
/ Recurrent asthma attacks (May hika) ✓
/ Chronic lung disease- ongoing PTB treatment (Sakit sa ✓
baga - ginagamot sa tuberculosis o TB)
/ COPD (Chronic Obstructive Pulmonary Disease) ✓
/ Cancer (Kanser) ✓
/ Blood Dyscrasias (Sakit sa dugo) ✓
/ Chronic Liver and Kidney diseases (Sakit sa atay at bato) ✓
/ Immunocompromised Status (Sobrang mahina ang resistensya) ✓
I have been experiencing the following symptoms ( 1 ) or have been subjected to
✓
situations ( 2,3,4 ) under Suspected Cases, and hereby agree not to physically
report for work and subject myself for further medical consultation and the
needed 14 days rest until medically cleared or tested negative to COVID19. I also
commit to submit proof of medical clearance/fit to work from the University
School Physicians.
I agree to be assigned Work From Home tasks (WFH) until allowed to return to
✓
work by my immediate superior and with endorsement from the School
Physician/HRD. Also, if I have the following conditions (5) under Vulnerable
Group, I hereby would agree on Work From Home tasks (employees) or
participate in online classes (students) until allowed to go back to work or school.
I hereby authorize Our Lady of Fatima University to collect and process data indicated herein for the purpose of effecting
control of COVID-19 infection. 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.

Signature Over Printed Name:

__JOHN MARK M. SALAZAR__ Date ____May 22,2020____