No. DATE AREA EMP NO.

1 11/112/2021 CARAGA EAST 16769

2 11/112/2021 CARAGA EAST 21846

7
 Birthday
NAME
Age
(Surname, Firstname, M.I.)
(mm/dd/yy)

MOSQUERA, JERRYPER 30

GAUANG, JESSICA 23
 CONSULTATION

Civil Status Present Address

S BACUAG, SURIGAO DEL NORTE

S HAYANGGABON, SURIGAO DEL NORTE

CONSULTATION

CONTACT NUMBER Email Address

mmosquerra@gmail.com
9079276973

9128904874 gaungjesica@gmail.com
 ASSOCIATE
DESIGNATION
STATUS

BRANCH ASSISTANT ACTIVE

BRANCH ASSISTANT ACTIVE

 NO. OF DAYS
ILLNESS
SICKED

FEVER 1

FEVER 1
MEDICINE/S TAKEN Travel History/Exposure
 TO BE FILLED OUT BY OSH IN-CHARGE

CLASSIFICATION EXPOSURE
N-CHARGE

OSH REMARKS
No. DATE AREA EMP NO.

7
 Birthday
NAME
Age
(Surname, Firstname, M.I.)
(mm/dd/yy)
 TO BE FILLED OUT BY AREA

Civil Status Present Address

E FILLED OUT BY AREA MANAGEMENT GROUP

CONTACT NUMBER Email Address

 ASSOCIATE
DESIGNATION
STATUS
PREVIOUS DOCTORS REMARK
 NO. OF DAYS
REASON FOR CONSULTATION HQ OR NOT
SICKED
TO BE FILLED OUT BY OSH IN-CHARGE

OSH REMARKS
Area Associates Name Age Gender
Contact # Reason for HQ
Test Result (if applicable) - RT Date HQ Started
PCR/Rapid Test (mm/dd/yy)
Date HQ Ended
(mm/dd/yy)
Health Status for the 14 days HQ
(Kindly indicate on what day did the assoc had symptoms)
 Test results needed
(Rapid test/RTAK/ test/CBC/Chest Xray)
Indicate if for Cocolife application
Area Emp # Associates Name
Birthdate
Age Civil Status Contact #
(mm/dd/yy)

One a
 Email Address Reason for HQ

One assoc, One sheet with attached labs

 Date HQ Started Date HQ Ended
Test Result (if applicable) - RT
PCR/Rapid Test
(mm/dd/yy) (mm/dd/yy)

abs
Present Health Status
(Symptomatic/Asymtomatic)
Doctors Previous Remarks, if any.