DLSU DAILY HEALTH SCREENING FORM

PLEASE PRINT

Date Day Time In Time Out Temp

Full Name Male
Gender Age
(Last, First M.I.) Female
Contact Number Alternate Contact No. of Immediate Relative
Home Address
A  C Employee  Contractual  ESP  Supplier  Parent  Others
Group Status Student  Applicant  Contractor  Locator  Guest _________
B  S N/A
Regular Work  Pick up / Delivery  Others
Nature of Visit Company
Appointment  Interview / Orientation _____________
Company Address

1. Do you  Yes  Yes  Yes  Yes

Fever Cough Colds Sore throat
currently have?  No  No  No  No
 Yes  Yes  Yes  Yes
Headache Diarrhea Body pains Fatigue
 No  No  No  No
2. During the last 14 days did you have any of the following symptoms like fever, cough,
 Yes  No
colds, sore throat, headache, diarrhea, body pains or fatigue?
3. Have you worked together or stayed in close environment of a confirmed COVID-19 case?  Yes  No
4. Did you have any contact with someone with fever, cough, colds, sore throat, within the
 Yes  No
past 2 weeks?
5. Have you travelled outside the Philippines in the last 14 days?  Yes  No

By signing this document, I hereby confirm and certify that all the above information I provided are TRUE and CORRECT as required
by RA 11469 otherwise known as “Bayanihan Act As One”. I hereby authorize DLSU to collect and process the data indicated herein for
the purpose of effecting control of the COVID-19 infection and may possibly use for research purposes. I understand that my personal
information is protected by RA 10173 (Data Privacy Act of 2012). I hereby certify that as of today, I am in good health and practicing
social distancing. I certify that I am voluntarily entering the work premises out of my own free will. I will NOT hold DLSU or my Agency
liable if I contracted COVID-19 in its premises as I cannot conclusively verify that I have been infected as a result of my visit to the
Company or elsewhere.

_________________________________________ ___________________________________ ___________

PRINTED NAME Signature Date

DLSU DAILY HEALTH SCREENING FORM

PLEASE PRINT

Date Day Time In Time Out Temp

Full Name Male
Gender Age
(Last, First M.I.) Female
Contact Number Alternate Contact No. of Immediate Relative
Home Address
A  C Employee  Contractual  ESP  Supplier  Parent  Others
Group Status Student  Applicant  Contractor  Locator  Guest _________
B  S N/A
Regular Work  Pick up / Delivery  Others
Nature of Visit Company
Appointment  Interview / Orientation _____________
Company Address

1. Do you  Yes  Yes  Yes  Yes

Fever Cough Colds Sore throat
currently have?  No  No  No  No
 Yes  Yes  Yes  Yes
Headache Diarrhea Body pains Fatigue
 No  No  No  No
2. During the last 14 days did you have any of the following symptoms like fever, cough,
 Yes  No
colds, sore throat, headache, diarrhea, body pains or fatigue?
3. Have you worked together or stayed in close environment of a confirmed COVID-19 case?  Yes  No
4. Did you have any contact with someone with fever, cough, colds, sore throat, within the
 Yes  No
past 2 weeks?
5. Have you travelled outside the Philippines in the last 14 days?  Yes  No

By signing this document, I hereby confirm and certify that all the above information I provided are TRUE and CORRECT as required
by RA 11469 otherwise known as “Bayanihan Act As One”. I hereby authorize DLSU to collect and process the data indicated herein for
the purpose of effecting control of the COVID-19 infection and may possibly use for research purposes. I understand that my personal
information is protected by RA 10173 (Data Privacy Act of 2012). I hereby certify that as of today, I am in good health and practicing
social distancing. I certify that I am voluntarily entering the work premises out of my own free will. I will NOT hold DLSU or my Agency
liable if I contracted COVID-19 in its premises as I cannot conclusively verify that I have been infected as a result of my visit to the
Company or elsewhere.

_________________________________________ ___________________________________ ___________

PRINTED NAME Signature Date