HEALTH & SAFETY CHECK

DECLARATION FORM
Complete Name:

Date: Day: Sex: Age:

Temperature: Time-In: Time-Out: Cellphone:

Home Address: Company Name:

Status: Employee Personal Visit

Others
Job Applicant Official Visit
Nature of Visit: Work Interview/Orientation Others If Others, state reason here:
Appointment Pickup/Delivery
Please answer these questions to the following health-related questions:
1. Are you experiencing? Sore Throat Yes No Headache? Yes No
Body Pains Yes No Fever for the past days? Yes No
2. Have you been in contact or stayed in a close environment with a person potentially exposed to COVID-19
and/or confirmed COVID-19 person, or anyone related or had contact with a confirmed Yes No
COVID-19 patient (friend, relative, community colleague, neighbor)?
3. Did you have any contact with someone with fever,cough,colds, sore throat in the past 2 weeks?
Yes No
4. Have you travelled outside the Philippines in the last 14 days? Yes No
5. Have you travelled to any area in NCR aside from your home in the last 14 days? Yes No
6. List the places you've been to yesterday
(For contact tracing purposes):
ADDITIONAL HEALTH & SAFETY QUESTIONNAIRE
1. How many are you in the house?
2. Is any one currently ill in the household? Yes No
If yes, what are the symptoms?
3. How long has the symptom existed?
4. Has a medical worker/doctor examined the patient? Yes No
5. Can you give an overview of the examination result? Yes No
6. Do you yourself manifest the following same symptoms:
Fever Yes No New Loss of Taste or Smell Yes No
Dry Cough Yes No Chills Yes No
Headache Yes No Nausea, Diarrhea, Vomiting Yes No
Head or muscle aches Yes No Difficulty breathing or shortness of
breath Yes No
Sore Throat Yes No
7. Have you attended a mass gathering/meeting in the last 14 days? Yes No
If Yes, where and when?
8. Did anyone from your household attend a mass gathering/meeting in the last 14 days? Yes No
If Yes, where and when?
By signing this document, I hereby authorize the RFDG CONSTRUCTION AND DEVELOPMENT CORPORATION 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 by RA 10173 (Data Privacy Act of 2012). I know that I am
required to provide truthful information as required by RA 11469 (Bayanihan to Heal As One Act).
I certify that as of today, I am submitting this Health & Safety Check Declaration and Questionnaire voluntarily
and with full knowledge and understanding of its safety purpose. It is also my genuine desire to preserve good
health and well- being of everyone in my workplace and my home.
The Company had completely and repeatedly provided and advised me of all COVID-19 required safety and
precautionary measures. For my part, I completely understand and I am fully aware of the risks and
safeguards I need to undertake for my safety and those of my co-workers.
In rendering this disclosure, I hereby render the Company free and harmless from any claim of any nature
whatsoever. I also declare that I have conducted myself in a safe and healthy manner inside the company as
well as outside, recognizing that any affliction that I gather outside may harm my fellow workers in the office.

Printed Name: Signature & Date:

RFDGCDC.EHSS.COVID.DECLARATION FORM.2020