Republic of the Philippines

NATIONAL POLICE COMMISSION

PHILIPPINE NATIONAL POLICE
HEADQUARTERS SUPPORT SERVICE
Camp BGen Rafael T Crame, Quezon City

Self Assessment / Checklist Form

Rank/Name: Date:
Age: Sex: Unit: Mobile Number:
Home Address:

Workplace Address: Occupation (for CIV/dependents):

HEALTH CONDITION TRAVEL HISTORY HISTORY OF EXPOSURE

(Within the last 14 days) (Within the last 14 days)
Presence of the following: Specify the place/s where Have you undergone COVID-19 testing:
YES NO you’ve been the past few ____ Yes
Fever days as well as the date: If yes, Date & Result:
Cough ____ No
(productive or Have you been in close contact with a
non-productive confirmed case/s of COVID-19?
cough) ____ Yes
Shortness of If yes, Date and Result:
breath
Cold ____ No
Sore throat If with recent travel, specify Specify health care facility:
Runny nose the location and date of
Nasal your travel abroad: Have you been in close contact who
Congestion works in a healthcare facility/hospital or is
Muscle pains currently living with you?
Headache ____ Yes
Difficulty of ____ No
Breathing Specify health care facility where your
Diarrhea friend/relative works:
Loss of sense
of Smell
Recent travel in the Have you been in close contact with a
Loss of sense
Philippines: relative or friend who had been to a
of Taste
____NCR country or place with confirmed cases of
NONE
Specify: ______________ COVID-19?
_____________________ ____Yes
____Others ____ No
If identified with presence of
Specify: ______________ Specify which country and date of close
the above, since when?
_____________________ contact with relative or friend:
Date: ________________

Declaration: The information I have given herein is true, correct, and complete. I understand that failure to answer any question or
any falsified response may have serious consequences. (Article 171, & 172 of the Revised Penal code of the Philippines and RA 11332.)

SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME

OF TRIAGE OFFICER/DATE SIGNED