ROBERTS AIPMC
EMPLOYEE HEALTH DECLARATION CHECK SHEET
Employee Name : _________________________ Department: _______
Complete Present Address: ______________________________________
___________________________________________________________
Contact No/Mobile No.: _____________________ Age:______
Temperature: ______
Sagutan ng buong katapatan ang mga sumusunod na katanungan.
A. Nakakaranas ka ba ng mga sumusunod na sintomas? Yes No
1 Lagnat (fever > 37.5C)
2 Nahihirapang huminga (difficulty of breathing)
3 May ubo (cough)
Pananakit ng lalamunan at masakit lumunok (sore throat)
4 4
5 May sipon (cold)
6 Pananakit ng ulo (headache)
7 Pananakit ng katawan (body pains)
8 Nagtatae (diarrhea)
9 Pagsusuka (vomiting)
10 Madaling mapagod ( fatigue)
Nawalan ng panlasa/pang-amoy (loss of sense of smell or
11 taste)
12 Pantal sa balat (rashes)
B. History of exposure sa covid patient Yes No
1 Mayroon ka bang kasama sa bahay na positibo,
sumailalim sa covid test o hinihinalang may COVID-19?
2 Nag-alaga ka ba ng COVID-19 patient?
Nag-lakbay ka ba o bumiyahe kasama sa iisang sasakyan
3 ang COVID-19 patient?
Mayroon ka bang kasama sa bahay na may lagnat, ubo,
4 sipon,sakit ng lalamunan o anumang sintomas ng covid?
If YES, Saang lugar? _____________________________________
kasama mula kailan _______ at hanggang kailan ________
Pinatutunayan ko na ang mga katanugan ay sinagot ko ng buong
katapatan at buong katotohanan. Gayundin, pinahihintulutan ko
ang kumpanya na gamitin itong mga inilahad kong impormasyon
upang ipatupad ang mga nararapat na kontrol at maiwasan ang
pagkalat ng COVID-19.
Naiintindihan ko na ang aking personal na impormasyon ay
protektado ng RA 10173, Data Privacy Act of 2012.
Employee Signature: ______________________
Date:________________ Time:_______________
ROBERTS AIPMC
EMPLOYEE HEALTH DECLARATION CHECK SHEET
Employee Name : _________________________ Department: _______
Complete Present Address: ______________________________________
___________________________________________________________
Contact No/Mobile No.: _____________________ Age:______
Temperature: ______
Sagutan ng buong katapatan ang mga sumusunod na katanungan.
A. Nakakaranas ka ba ng mga sumusunod na sintomas? Yes No
1 Lagnat (fever > 37.5C)
2 Nahihirapang huminga (difficulty of breathing)
3 May ubo (cough)
Pananakit ng lalamunan at masakit lumunok (sore throat)
5 May sipon (cold)
6 Pananakit ng ulo (headache)
7 Pananakit ng katawan (body pains)
8 Nagtatae (diarrhea)
9 Pagsusuka (vomiting)
10 Madaling mapagod ( fatigue)
Nawalan ng panlasa/pang-amoy (loss of sense of smell or
11 taste)
12 Pantal sa balat (rashes)
B. History of exposure sa covid patient Yes No
1 Mayroon ka bang kasama sa bahay na positibo,
sumailalim sa covid test o hinihinalang may COVID-19?
2 Nag-alaga ka ba ng COVID-19 patient?
Nag-lakbay ka ba o bumiyahe kasama sa iisang sasakyan ang
3 COVID-19 patient?
Mayroon ka bang kasama sa bahay na may lagnat, ubo,
4 sipon,sakit ng lalamunan o anumang sintomas ng covid?
If YES, Saang lugar? _____________________________________
kasama mula kailan _______ at hanggang kailan ________
Pinatutunayan ko na ang mga katanugan ay sinagot ko ng buong
katapatan at buong katotohanan. Gayundin, pinahihintulutan ko
ang kumpanya na gamitin itong mga inilahad kong impormasyon
upang ipatupad ang mga nararapat na kontrol at maiwasan ang
pagkalat ng COVID-19.
Naiintindihan ko na ang aking personal na impormasyon ay
protektado ng RA 10173, Data Privacy Act of 2012.
Employee Signature: ______________________
Date:________________ Time:_______________
ROBERTS AIPMC
EMPLOYEE HEALTH DECLARATION CHECK SHEET
Employee Name : _________________________ Department: _______
Complete Present Address: ______________________________________
___________________________________________________________
Contact No/Mobile No.: _____________________ Age:______
Temperature: ______
Sagutan ng buong katapatan ang mga sumusunod na katanungan.
A. Nakakaranas ka ba ng mga sumusunod na sintomas? Yes No
1 Lagnat (fever > 37.5C)
2 Nahihirapang huminga (difficulty of breathing)
3 May ubo (cough)
Pananakit ng lalamunan at masakit lumunok (sore throat)
4
5 May sipon (cold)
6 Pananakit ng ulo (headache)
7 Pananakit ng katawan (body pains)
8 Nagtatae (diarrhea)
9 Pagsusuka (vomiting)
10 Madaling mapagod ( fatigue)
Nawalan ng panlasa/pang-amoy (loss of sense of smell or
11 taste)
12 Pantal sa balat (rashes)
B. History of exposure sa covid patient Yes No
1 Mayroon ka bang kasama sa bahay na positibo,
sumailalim sa covid test o hinihinalang may COVID-19?
2 Nag-alaga ka ba ng COVID-19 patient?
Nag-lakbay ka ba o bumiyahe kasama sa iisang sasakyan
3 ang COVID-19 patient?
Mayroon ka bang kasama sa bahay na may lagnat, ubo,
4 sipon,sakit ng lalamunan o anumang sintomas ng covid?
If YES, Saang lugar? _____________________________________
kasama mula kailan _______ at hanggang kailan ________
Pinatutunayan ko na ang mga katanugan ay sinagot ko ng buong
katapatan at buong katotohanan. Gayundin, pinahihintulutan ko
ang kumpanya na gamitin itong mga inilahad kong impormasyon
upang ipatupad ang mga nararapat na kontrol at maiwasan ang
pagkalat ng COVID-19.
Naiintindihan ko na ang aking personal na impormasyon ay
protektado ng RA 10173, Data Privacy Act of 2012.
Employee Signature: ______________________
Date:________________ Time:_______________
ROBERTS AIPMC ROBERTS AIPMC ROBERTS AIPMC
VISITOR'S HEALTH DECLARATION CHECK SHEET VISITOR'S HEALTH DECLARATION CHECK SHEET VISITOR'S HEALTH DECLARATION CHECK SHEET

Name : _____________________________________ Age: _______
Complete Present Address: ______________________________________
___________________________________________________________
Date of visit: _____________________ Time of Visit:______
Temperature: ______
Name : _____________________________________ Age: _______
Complete Present Address: ______________________________________
___________________________________________________________
Date of visit: _____________________ Time of Visit:______
Temperature: ______
Name : _____________________________________ Age: _______
Complete Present Address: ______________________________________
___________________________________________________________
Date of visit: _____________________ Time of Visit:______
Temperature: ______

Please answer the following questions truthfully: Please answer the following questions truthfully: Please answer the following questions truthfully:

A. Are you experiencing the following symptoms? Yes No A. Are you experiencing the following symptoms? Yes No A. Are you experiencing the following symptoms? Yes No
1 Fever (> 37.5 degree Centigrade) 1 Fever (> 37.5 degree Centigrade) 1 Fever (> 37.5 degree Centigrade)
2 Difficulty of breathing 2 Difficulty of breathing 2 Difficulty of breathing
3 Cough 3 Cough 3 Cough
4 Sore throat 4 Sore throat 4 Sore throat
5 Cold 5 Cold 5 Cold
6 Headache 6 Headache 6 Headache
7 Body Pain 7 Body Pain 7 Body Pain
8 Diarrhea 8 Diarrhea 8 Diarrhea
9 Vomiting 9 Vomiting 9 Vomiting
10 Fatigue 10 Fatigue 10 Fatigue
11 Loss of sense of smell or taste 11 Loss of sense of smell or taste 11 Loss of sense of smell or taste
12 Rashes 12 Rashes 12 Rashes
B. History of exposure sa covid patient Yes No B. History of exposure sa covid patient Yes No B. History of exposure sa covid patient Yes No
1 Are you living with the same household as COVID 1 Are you living with the same household as COVID 1 Are you living with the same household as COVID
patient? patient? patient?
2 Providing direct care for COVID patient? 2 Providing direct care for COVID patient? 2 Providing direct care for COVID patient?
Have you travelled together with COVID patient in any Have you travelled together with COVID patient in any Have you travelled together with COVID patient in any
3 kind of transporation? 3 kind of transporation? 3 kind of transporation?

Are you living with the same household with fever, cough Are you living with the same household with fever, cough Are you living with the same household with fever, cough
4 and colds, sore throat or any COVID symptoms? 4 and colds, sore throat or any COVID symptoms? 4 and colds, sore throat or any COVID symptoms?

If YES, Where? _____________________________________ If YES, Where? _____________________________________ If YES, Where? _____________________________________

from when _______ to when ________ from when _______ to when ________ from when _______ to when ________

This is to certify that the information I provided herein is true,
accurate and complete. I hereby authorize Roberts 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 RA 10173,
Data Privacy Act of 2012.
This is to certify that the information I provided herein is true,
accurate and complete. I hereby authorize Roberts 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 RA 10173,
Data Privacy Act of 2012.
This is to certify that the information I provided herein is true,
accurate and complete. I hereby authorize Roberts 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 RA 10173,
Data Privacy Act of 2012.

Signature: ______________________ Signature: ______________________ Signature: ______________________

Date:________________ Time:_______________ Date:________________ Time:_______________ Date:________________ Time:_______________